Every finding on record at The Laurels of Chagrin Falls

Based on personnel record review, review of the facility ' s Background Check log, review of the [NAME] Municipal Court docket, staff schedule review, staff member handbook review, review of the Ohio Administrative Code (OAC), and interview, the facility failed to ensure direct care staff, Certified Nurse Aide (CNA) #46, did not continue to provide direct care to residents after she was convicted of a disqualifying offense according to State law. This had the potential to affect all residents residing in the facility. The census was 34.Findings include:Review of Certified Nurse Aide (CNA) #46's personnel record revealed a hire date of 06/04/25. Review of the Ohio Department of Health Nurse Aide Registry (NAR) (within CNA #46's personnel record) dated 06/03/25 revealed CNA #46 was eligible to work and in good standing. Review of the Ohio Attorney General Criminal History Record Check dated 06/13/25 (within CNA #46's personnel record) revealed CNA #46 had a criminal history and was arrested and charged with Disorderly Conduct and Domestic Violence on 05/21/25. Review of the Employment Reference Check forms dated 06/03/25 revealed a reference check from a former employer was obtained for CNA #46 and a reference check from a former employer was attempted for CNA #46.Review of the facility's Background Check Log revealed CNA #46 had a State Records check submitted on 06/13/25 then received on 06/21/25. The log indicated CNA #46 was hired.Review of the [NAME] Municipal Court docket review revealed CNA #46 was convicted of 2919.25(A) - (1) Misdemeanor first degree Domestic Violence on 10/15/25. CNA #46 was on probation from 10/15/25 to 10/15/26 for the charge of domestic violence.Review of the facility document revealed a printed-out Ohio Administrative Code Rule 3701-13-06 for Personal character standards with CNA #46's name at the top with a date of 11/12/25. The document had hand written notes for each standard including under section 5 where it states If the offense is an offense of violence as defined in paragraph (J) of rule 3701-13-01 of the Administrative Code, other than one listed in paragraph (A)(3) of this rule; and (b) At least five years have elapsed since the date the applicant was fully discharged from imprisonment, probation and parole. The words recent situation were written after this standard.Review of the nurse and CNA staff schedule from 10/15/25 to 12/09/25 revealed CNA #46 worked from 3:00 P.M. to 11:00 P.M. on the following dates: 10/16/25, 10/17/25, 10/20/25, 10/21/25, 10/22/25, 10/23/25, 10/25/25, 10/26/25, 10/28/25, 10/29/25, 10/30/25, 11/03/25, 11/04/25, 11/05/25, 11/06/25, 11/08/25, 11/09/25, 11/12/25, 11/13/25, 11/14/25, 11/18/25, 11/19/25, 11/22/25, 11/23/25, 11/25/25, 11/26/25, 11/28/25, 12/01/25, 12/03/25, 12/06/25, and 12/07/25.Interview on 12/09/25 at 11:20 A.M. with Human Resources Director (HRD) #47 (with the interim Administrator present) revealed HRD #47 was aware CNA #46 was arrested for Domestic Violence prior to hire, however CNA #46 was not convicted at the time of hire.Interview on 12/09/25 at 11:55 A.M. with CNA #46 revealed CNA #46 was arrested for domestic violence in May 2025 then she was convicted of a first-degree misdemeanor for domestic violence in October 2025. CNA #46 stated she discussed the arrest with Former Administrator #48 in August 2025 since CNA #46 was aware the disciplinary number for domestic violence was a disqualifying offense. CNA #46 stated the facility used character standards for CNA #46 to continue working at the facility. CNA #46 also notified the interim Administrator who obtained paperwork from the corporate office for her personnel file.A follow-up interview on 12/09/25 at 12:10 P.M. with HRD #47 (with the Administrator present) revealed HRD #47 was aware CNA #46 had been convicted of domestic violence, however CNA #46 continued employment with the facility due to CNA #46 meeting personal character standards.Interview on 12/09/25 at 1:00 P.M. and 1:40 P.M. with the interim Administrator revealed she (interim Administrator) and HRD #47 filled out CNA #46's personal character standards form together with guidance from the Corporate HRD. The interim Administrator verified CNA #46 had been convicted of domestic violence, which was a disqualifying offense according to State law. The interim Administrator also verified CNA #46 was recently convicted, still on probation until 10/15/26, CNA #46 did not meet (5) (b) of Rule 3701-13-06 for personal character standards and CNA #46 had access to all residents while CNA #46 worked in the facility since the conviction.Review of the facility's Staff Member Handbook, section titled Category III Work Rules, revised 06/04/24 revealed these offenses are the most serious and violations will subject a Staff Member to immediate termination. If an incident or situation requires further investigation, staff may be placed on suspension without pay pending an investigation and, if verified, will lead to termination.56. Staff members are responsible to report immediately upon being arrested, arraigned and/or convicted for one or more relevant criminal offenses under each respective state or federal law offenses. A Staff Member may be suspended without pay when charged with the respective state or federal law offense. Conviction of a respective state or federal law offense may result in termination.Review of the Rule 3701-13-05 Disqualifying offenses in the Ohio Administrative Code (OAC) Chapter 3701-13 Hiring of Direct-Care Provider (DCP) Employees effective 12/08/23 revealed, Except as set forth in the personal character standards established in rule 3701-13-06 of the Administrative Code, no DCP is allowed to employ a person in a position that involves providing direct care to an older adult if the person has been convicted of or pleaded guilty to: (1) A violation of any of the following sections of the Revised Code: .(rr) 2919.25 -- Domestic violence.Review of the Rule 3701-13-06 Personal character standards in the OAC Chapter 3701-13 Hiring of Direct-Care Provider (DCP) Employees effective 12/08/23 revealed, (A) A DCP may employ an applicant who has been convicted of or pleaded guilty to an offense listed in paragraph (A) of rule 3701-13-05 of the Administrative Code in a position involving direct care to an older adult, if all of the following standards are met:(1) The applicant is not a repeat violent offender as defined in paragraph (M) of rule 3701-13-01 of the Administrative Code;(2) The offense is not a sexually oriented offense as defined in paragraph (N) of rule 3701-13-01 of the Administrative Code;(3) The offense is not a violation of any of the following sections of the Revised Code or a violation of an existing or former law of this state, any other state, or the United States, if the offense is substantially equivalent to the offenses or violations described in the following sections of the Revised Code: 2903.01 (aggravated murder), 2903.02 (murder), 2903.03 (voluntary manslaughter), 2903.34 (patient abuse or neglect), or 3716.11 (placing harmful objects in food or confection);(4) If the applicant has more than one theft related offense as defined in paragraph (Q) of rule 3701-13-01 of the Administrative Code;(a) The victim of either offense was not an older adult; and(b) At least seven years have elapsed since the date the applicant was fully discharged from imprisonment, probation, or parole for the most recent offense;(5) If the offense is an offense of violence as defined in paragraph (J) of rule 3701-13-01 of the Administrative Code, other than one listed in paragraph (A)(3) of this rule; and(a) The victim of the offense was not an older adult; and(b) At least five years have elapsed since the date the applicant was fully discharged from imprisonment, probation and parole; or(6) If the offense is not an offense of violence as defined in paragraph (J) of rule 3701-13-01 of the Administrative Code or an offense listed in paragraph (A)(3) of this rule; and(a) The applicant is either discharged from imprisonment, sentenced to probation, is fined or is on parole; and(b) The applicant provides proof that all conditions regarding fulfillment of sentencing requirements are being met.(7) The applicant's character is such that it is unlikely that the applicant will harm an older adult. In making that determination, the chief administrator is obligated to consider the following factors for each offense:(a) The applicant's age at the time of the offense;(b) Regardless of whether the applicant knew the victim prior to the committing of the offense, the age and mental capacity of the victim;(c) The nature and seriousness of the offense;(d) The number of previous offenses or length of time since the most recent conviction or guilty plea;(e) The degree to which the applicant participated in the offense and the degree to which the victim contributed to or provoked the offense;(f) The likelihood that the circumstances leading to the offense will reoccur;(g) The applicant's employment record;(h) The applicant's efforts at rehabilitation and the results of those efforts;(i) If known, whether the applicant has been convicted of or pleaded guilty to any violation of an existing or former municipal ordinance substantially equivalent to any offense listed or described in rule 3701-13-05 of the Administrative Code;(j) Whether any criminal proceedings are pending; and(k) Any other factors related to the position that the chief administrator considers relevant to the performance of job duties.(B) If the applicant fails to provide proof that the personal character standards listed in this rule are met, or if the DCP determines that the proof offered by the applicant is inconclusive, the applicant cannot be employed in a position that involves providing direct care to older adults.This deficiency represents non-compliance investigated under Complaint Number 2637627.

Based on medical record review, resident interview, and staff interview, the facility failed to ensure sufficient bathing was provided to all dependent residents. This affected two (Residents #1 and #20) of three residents reviewed for activities of daily living (ADL). The census was 45. Findings Include: 1. Resident #1 was admitted to the facility on [DATE]. His diagnoses were infection and inflammatory reaction due to indwelling urethral catheter, sepsis due to MRSA, COPD, muscle wasting and atrophy, dysphagia, type II diabetes, urinary tract infection, obstructive and reflux uropathy, unspecified severe protein calorie malnutrition, congestive heart failure, pleural effusion, hypertensive heart and chronic kidney disease, acute kidney failure, atrial fibrillation, anemia, aortic stenosis, and hyperlipidemia. Review of his Minimum Data Set (MDS) assessment, dated 04/17/25, revealed he had mild cognitive impairment and was dependent on staff for bathing/showering. Review of Resident #1 current shower schedule revealed he was scheduled to have a bath/shower on Mondays and Thursdays in the evening. Review of Resident #1 shower logs/documentation, dated 04/10/25 to 06/20/25, revealed the following dates did not have documentation as shower/baths being offered to Resident #1: 04/28/25, 05/01/25, 05/05/25, 05/08/25, and 05/15/25. Interview with Director of Nursing (DON) and Administrator on 06/20/25 at 3:30 P.M. confirmed there is no documentation for Resident #1 being offered a bath/shower on the above listed days. They confirmed the resident needs at least some physical assistance and/or reminders to take a bath/shower from staff. 2. Resident #20 was admitted to the facility on [DATE]. His diagnoses were cognitive social or emotional deficit following other cerebrovascular disease, alcoholic cirrhosis of liver, dementia, patient's non-compliance with other medical treatment, adult failure to thrive, unspecified severe protein calorie malnutrition, edema, cellulitis of left axilla and right upper limb, anxiety disorder, asthma, hoarding disorder, delusional disorder, dietary folate deficiency anemia, restlessness and agitation, and alcohol abuse. Review of his MDS assessment, dated 04/10/25, revealed he was cognitively intact. Review of Resident #20 MDS assessment, section GG, dated 04/10/25, revealed he refused to take a bath/shower during that time to determine his ability level. Review of Resident #20 current shower schedule revealed he was scheduled to have a bath/shower on Tuesdays and Fridays in the evening. The facility provided a list identifying Resident #20 needing physical assistance with bathing/showering. Review of Resident #20 shower logs/documentation, dated 04/10/25 to 06/20/25, revealed the following dates did not have documentation as shower/baths being offered to Resident #1: 03/27/25, 04/14/25, 04/21/25, 04/28/25, 05/09/25, 05/16./25, 05/30/25, and 06/06/25. Interview with Resident #20 on 06/20/25 at 2:30 P.M. confirmed he is not offered a bath/shower when he needs or wants it. He confirmed he will refuse at times, and there are times he does want to wash himself in the sink, but he stated he is not always offered a bath/shower when he desires it. Interview with DON and Administrator on 06/20/25 at 3:30 P.M. confirmed there is no documentation for Resident #20 being offered a bath/shower on the above listed days. They confirmed the resident needs at least some physical assistance and/or reminders to take a bath/shower from staff. Both confirmed Resident #20 will refuse care, including bath/showers quite often, but they confirmed there should be documentation for each scheduled bath/shower; whether it was completed or refused. This deficiency represented non-compliance investigated under Complaint Number OH00165113.

Based on observation, record review and interview, the facility failed to ensure Resident #3's nutritional supplement was implemented as planned. This affected one (Resident #3) of two residents reviewed for nutrition. Findings include: Review of Resident #3's medical record revealed the resident was admitted on [DATE] with diagnoses including Alzheimer's disease, hypertensive heart disease with heart failure and mild cognitive impairment. Review of Resident #3's physician orders revealed an order dated 10/03/24 for a regular diet, regular texture, thin consistency. Review of Resident #3's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited cognitive impairment. Review of Resident #3's dietary progress note dated 12/31/24 at 11:48 A.M. revealed the resident was slightly underweight and the regular diet remained tolerated. The resident had between meal supplements in place for nutrition support and snacks were noted in the resident's room. Review of Resident #3's lunch meal ticket dated 02/05/25 revealed the resident's standing orders were ice cream and four fluid ounces of water. Observation on 02/05/25 at 12:45 P.M. revealed Resident #3 was provided turkey, stuffing, green bean casserole, pumpkin pie, a roll and grape juice. Resident #3 was not provided the ice cream as ordered for the resident's weight loss. Interview on 02/05/25 at 12:55 P.M. with Nutrition Associate #870 indicated she was unsure why Resident #3 did not have the ice cream on his tray when it was on the meal ticket. Review of the menus and spreadsheets revealed the lunch meal consisted of three ounces of roasted savory turkey, four ounces of savory stuffing, four ounces of green bean casserole, one dinner roll and a slice of pumpkin pie. Review of the Nutritional Supplementation policy revised 10/05/24 revealed it was the policy of the facility to provide nutritional supplements when clinically necessary to maintain weight, health and hydration of residents. Supplements would be considered a last resort measure after substitutes, food alternatives, and liberalizing the diet had been attempted.

Based on observation, record review and interview, the facility failed to ensure Resident #11's pressure ulcer wound care was completed as ordered. This affected one (Resident #11) of one resident reviewed for pressure ulcer wounds. Findings include: Review of Resident #11's medical record revealed the resident was admitted [DATE] with diagnoses including senile degeneration of the brain, essential hypertension and major depressive disorder. Review of Resident #11's care plans revealed an intervention dated 10/29/24 for treatments to skin impairments as ordered. Review of Resident #11's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #11's physician orders revealed an order dated 01/10/25 to cleanse the left heel wound with normal saline, pat dry, apply betadine to the wound and cover with an abdominal (ABD) pad and Kerlix every night shift for wound care. Review of Resident #11's physician orders revealed an order dated 01/23/25 to cleanse the right lateral ankle and right lateral foot wound with normal saline, pat dry, apply betadine and cover with an ABD pad and Kerlix every night shift and as needed. Review of Resident #11's Skin and Wound Evaluation form dated 01/30/25 revealed the resident had an Unstageable left heel pressure wound (full- thickness tissue loss where the depth cannot be assessed due to the presence of necrotic tissue such as hard black or brown eschar tissue) which measured 2.3 centimeters (cm) length by 2.1 cm depth. Review of Resident #11's Skin and Wound Evaluation form dated 01/30/25 revealed the resident had a right ankle deep tissue injury (DTI) or pressure induced damage to underlying tissue pressure wound which measured 1.5 cm length by 1.3 cm width. The pressure wound bed had eschar (tan, brown or black dead tissue that sheds or falls off from the skin). Review of Resident #11's Skin and Wound Evaluation form dated 01/30/25 revealed the resident had a Stage three (full thickness skin loss) right middle heel pressure ulcer which measured 3.7 cm length by 4.1 cm depth. Review of Resident #11's physician orders revealed an order dated 01/30/25 to cleanse the right heel wound with normal saline, pat dry, apply betadine moistened 2 x 2 gauze and cover with an ABD and Kerlix every nightshift for wound care. Review of Resident #11's Skin and Wound Evaluation form dated 01/30/25 revealed the resident had a right lateral forefoot DTI pressure wound which measured 1.0 cm length by 1.6 cm width. Observation on 02/05/25 at 3:16 P.M. to 3:32 P.M. with Registered Nurse (RN) Wound Nurse #816 of Resident #11's pressure ulcer wound care revealed RN Wound Nurse #816 setup her field with the wound care dressings on the resident's overbed table, washed her hands and put on gloves, used scissors to cut through the previous dressings to the left foot and then the right foot, used normal saline to remove the previous dressing to the left foot which was partially stuck to the heel and then used normal saline to remove the dressing to the right foot and right lateral ankle which was partially stuck to the heel, removed her gloves and washed her hands, put on new gloves, placed a 2 x 2 dressing with iodine to the left heel, covered with an ABD pad and wrapped with Kerlix, placed a 2 x 2 dressing with iodine on the right heel, right lateral foot and ankle wounds, covered with an ABD pad and wrapped with Kerlix. The nurse placed tape on the Kerlix to both the right and left feet with the date and time written on the tape, placed the dressing packages in the trash, removed her gloves and washed her hands. Regional RN #872 assisted RN Wound Nurse #816 with Resident #11's pressure ulcer wound care. Interview on 02/05/25 at 3:51 P.M. with Regional RN #872 confirmed RN Wound Nurse #816 did not clean Resident #11's bilateral heels with normal saline and pat dry prior to placing the 2 x 2 dressings with iodine on the resident's bilateral heels as ordered. Review of the Clean Dressing Change policy dated 09/18/23 revealed to check the physician order for the correct treatment, establish a clean field, perform hand hygiene, remove the old dressing and discard, remove gloves, perform hand hygiene, apply clean gloves, cleanse the wound site gently with the solution ordered, apply any medication as ordered, dress the wound site, discard soiled materials, remove gloves and wash the hands.

Based on record review and interview the facility failed to ensure care conferences were completed quarterly for Residents #13 and #14. This affected two of three residents whose records were reviewed for care conferences. The facility census was 42. Findings include: 1. Record review revealed Resident #14 was admitted [DATE] with diagnoses of chronic obstructive pulmonary disease, malignant neoplasm of prostate, paranoid schizophrenia, and unspecified dementia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 scored 9 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated a moderate cognitive impairment. Review of the functional abilities section of the MDS assessment revealed no impairment however Resident #14 utilized a wheelchair for locomotion. Review of the completed care conference documentation revealed Resident #14 had care conferences 03/26/24 and 08/26/24. There was no evidence found in the medical record that indicated a care conference were completed quarterly in 2024. Review of the progress notes from March 2024 to February 2025 provided no information as to why the care conferences were not held. Interview on 02/06/25 at 11:55 A.M. with Social Service Designee (SSD) #866 confirmed Resident #14's last care conference was completed 08/26/24. 2. Record review revealed Resident #13 was admitted [DATE] with diagnoses of unspecified dementia, senile degeneration of the brain, chronic diastolic congestive failure, and unspecified protein-calorie malnutrition. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #13 had a BIMS score of 3 out of 15 which indicated severe cognitive impairment. Review of functional abilities revealed Resident #13 required maximal assistance with toileting, dressing, showers, and moderate assistance with transfers. Review of the completed care conferences documentation revealed Resident #13 had care conferences 03/25/24, 05/24/24, 08/19/24 and 01/16/25. No evidence was found in the record that indicated a care conference was completed as required in November 2024. Review of the November 2024 progress notes provided no information as to why the care conference was not held. Interview on 02/06/25 at 11:39 A.M. with SSD #866 revealed the missed November care conference was discovered after an audit was performed which prompted SSD #866 to schedule and complete a care conference 01/16/25. Review of the Care Planning Conference Policy revised 06/24/21 revealed Interdisciplinary Care Conferences will be held for the following reasons: Admission, Annually, Quarterly, Significant change, discharge as needed, and as needed.

Based on observation and interview, the facility failed to ensure Resident #36's expired insulin was discarded as appropriate. This affected one (Resident #36) of five residents observed for medication administration. Findings include: Observation on [DATE] at 12:15 P.M. with Licensed Practical Nurse (LPN) #822 revealed LPN #822 completed blood glucose testing for Resident #36 with a result of 175. LPN #822 then administered three units of Humalog fast acting insulin into the resident's right arm using a Humalog Kwikpen. The date first used written on the Kwikpen in marker was [DATE]. Interview on [DATE] at 12:20 P.M. with LPN #822 confirmed Resident #36's Humalog Kwikpen was expired and should have been discarded after 28 days after first being used. The Humalog Kwikpen expired [DATE]. Review of the Insulin Lispro (Humalog) KwikPen Instructions for Use form revised [DATE] revealed an in-use pen should be stored at room temperature up to 86 degrees Fahrenheit and away from heat and light. The pen should be thrown away after 28 days, even if the pen still had insulin left in the pen.

Based on observation, record review and interview, the facility failed to ensure the blood glucose testing (BGT) machine/glucometer was appropriately cleaned and disinfected to prevent the potential cross-contamination of blood borne pathogens affecting one resident (Resident #36) with the potential to affect an additional resident (Resident #24) whose medications were stored in the Nurse Station 2 medication administration cart. The facility also failed to ensure appropriate hand hygiene, appropriate glove use, and appropriate cleaning technique were implemented during Resident #29's catheter care affecting one resident (Resident #29) of two residents reviewed for catheter care. Findings include: 1. Review of Resident #24's medical record revealed the resident was admitted on [DATE] with diagnoses including hemiplegia, type two diabetes and chronic obstructive pulmonary disease. Review of Resident #24's physician orders revealed an order dated 10/30/24 for sliding scale insulin; inject Humalog as per sliding scale with meals for diabetes if the blood glucose test was 151 to 200 administer two units; 201 to 250 administer four units; 251 to 300 administer six units; 301 to 350 administer eight units; 351 to 400 administer 10 units and notify the provider if the blood sugar was above 400. Review of Resident #36's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dementia, altered mental status, Parkinson's disease and type two diabetes. Review of Resident #36's physician orders revealed an order dated 04/09/24 to administer three units of Humalog fast acting insulin before meals for diabetes. Observation on 02/03/25 at 11:51 A.M. with revealed Licensed Practical Nurse (LPN) #822 obtained a BGT for Resident #24 with a result of 112 and no insulin was administered. The nurse was observed cleaning the glucometer after the BGT with a 70 percent alcohol prep pad. Observation on 02/03/25 at 12:15 P.M. revealed LPN #822 obtained Resident #36's BGT with a result of 175. She then administered three units of Humalog fast acting insulin. LPN #822 was observed cleaning the glucometer with a 70 percent alcohol prep pad. Interview on 02/03/25 at 12:20 P.M. with LPN #822 revealed she did not clean the glucometer with a bleach wipe to prevent the potential of cross-contamination of blood borne pathogens because no bleach wipes were available on her medication administration cart. Interview on 02/06/25 at 10:45 A.M. with Registered Nurse #817 confirmed two residents receive BGT's using a glucometer on the Nurse Station 2 medication cart including Residents #24 and #36. Review of the facility Disinfection of Noncritical Patient Care Equipment policy last reviewed 11/18/24 revealed to clean and disinfect the patient care equipment with an EPA (Environmental Protection Agency) approved and facility approved disinfectant following the label's safety precautions and directions for use. Review of the Food and Drug Administration (FDA) guidance on Blood Glucose Meters or BGT machines revealed the disinfection solvent chosen should be effective against HIV, Hepatitis C, and Hepatitis B virus. Outbreak episodes have been largely due to transmission of Hepatitis B and C viruses. However, of the two, Hepatitis B virus was the most difficult to kill. Please note that 70 percent ethanol solutions were not effective against viral bloodborne pathogens and the use of 10 percent bleach solutions may lead to physical degradation of the device. Review of the undated Evencare G2 glucometer manufacturer directions revealed the meter and lancing device were validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. Bleach disinfectants were validated for disinfecting the meter and lancing device including Dispatch Hospital Cleaner with Bleach, Medline Micro-Kill Disinfecting Wipes; Clorox Healthcare Bleach Germicidal and Medline Micro-Kill Bleach Germicidal Bleach Wipes. 48567 2. Review of the medical record for Resident #29 revealed an admitted [DATE] with diagnoses including unspecified dementia, paranoid schizophrenia, hyperlipidemia, benign neoplasm of the colon, constipation, bilateral age-related nuclear cataracts, transient cerebral ischemic attack, benign prostatic hyperplasia (BPH), and obstructive and reflux uropathy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 12/27/24 revealed Resident #29 had intact cognition and required moderate assistance with toileting hygiene. Further review of the MDS revealed Resident #29 had an indwelling catheter and was frequently incontinent of bowel. Review of the care plan dated 06/03/22 (last reviewed 10/15/24) revealed Resident #29 was at risk for urinary tract infection and catheter-related trauma related to the presence of an indwelling catheter for urinary retention, BPH, and obstructive uropathy. Intervention included observation, documentation and reporting of catheter related discomfort, monitoring and reporting signs and symptoms of infection, and providing catheter care per policy. Review of the physician orders revealed an order dated 12/12/24 for Resident #29 to have catheter care every shift. Observation on 02/05/25 from 3:10 P.M. to 3:15 P.M. revealed Resident #29 received catheter and perineal care from Certified Nurse Aide (CNA) #828, assisted by CNA #831. The Director of Nursing (DON) was also present for the observation and verbally instructed the CNAs Remember to change your gloves prior to them beginning the procedure. Further observation revealed that soap was added to the wash basin and the same basin was used for both washing and rinsing the catheter and perineal area. During the observation, CNA #828 wore the same gloves throughout the entire procedure, including washing and rinsing (with soapy water) the catheter , which had a small clump of a dried, sticky substance on it, and providing perineal area, pulling up Resident #29's dry brief and pants, straightening his bedding, and adjusting the bed height. Interview on 02/05/25 at 3:18 P.M. with CNA #828 confirmed she used the soapy water to rinse the catheter and perineal area but should have used clean water. Further interview with CNA #828 confirmed she did not change her gloves between washing the catheter and perineal area and then completing the rest of the clean procedure with soiled gloves. During the interview, CNA #828 revealed she was unaware gloves should be changed between moving from a soiled task to a clean task and stated, I never knew that. Review of the Centers for Disease Control (CDC) and Prevention website guidance titled Clinical Safety: Hand Hygiene for Healthcare Workers revealed gloves should be changed if gloves became soiled with body fluids, after a task, and when moving from work on a soiled body site to a clean site, even when on the same person.

Based on observation, interview and menu spreadsheet review, the facility failed to follow the menu as written. This affected two residents (#16 and #34) of two residents receiving a puree diet. Facility census was 36. Findings include: Review of the menu spreadsheet for week two, Thursday corresponding to 08/29/24 revealed portions of the menu were to be served as followed for those receiving pureed meals: five ounces pureed sloppy joes, four ounces pureed tater tots, four ounces pureed lima beans, six ounces pureed soup of the day and two ounces pureed cookie (no nuts). Review of the facility resident diet list revealed Resident #16 and #34 received pureed diets. Observation of lunch tray service on 08/29/24 at 12:24 P.M. revealed the trays for the two residents on a pureed diet (Resident #16 and Resident #34) were at the end of the tray line. Certified Dietary Manager (CDM) #52 was plating meals during service and brought two divided plates over to the serving area. A blue #16-scoop (two ounces) was placed into the pan with the pureed sloppy joe meat, a blue #16-scoop was placed into the pan of pureed butter beans and a spatula was noted in the pan of pureed tater tots and a square container of room temperature pureed bread was noted to the left of the serving area. Resident #34's plate included one #16-scoop of pureed beans, a #16-scoop of pureed sloppy joe meat on top of a square (not used with a measuring device thus an unknown amount) of pureed bread with another square of pureed bread on top, and a dollop of pureed tater tots applied to the plate with the spatula (not used with a measuring device thus an unknown amount). Resident #16's plate consisted of one #16-scoop of pureed beans, two #16-scoops of pureed sloppy joe meat on top of two squares (not used with a measuring device thus an unknown amount) of pureed bread with another square of pureed bread on top of each sandwich, and a dollop of pureed tater tots applied to the plate with the spatula (not used with a measuring device thus an unknown amount) as she was ordered double portions. Interview on 08/29/24 at 12:34 P.M. with CDM #52 verified the observed pureed beans and pureed tater tots were under served and did not meet the four ounce serving sizes as written on the diet spreadsheet. CDM #52 stated she did not have the spreadsheet available when she was preparing the purees for the lunch meal. Follow up interview on 08/29/24 at 1:14 P.M. with CDM #52 and the Administrator present revealed CDM #52 did not usually serve at trayline and was unable to provide oversight during trayline as a staff member had called off that date. This deficiency represents non-compliance investigated under Complaint Number OH00155938.

Based on observation, interview and record review, the facility failed to provide routine scheduled showers for three residents reviewed, Resident #38, #44, and #6, of four residents reviewed for showers. The facility census was 45. Findings include: 1.Record review for Resident #38 revealed an admitted [DATE]. Diagnosis included paranoid schizophrenia, unsteady on feet, bipolar disorder, dementia, anxiety disorder, muscle weakness, and paranoid personality disorder. Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was severely cognitively impaired. Resident #38 required extensive assistants with personal hygiene. Record review of the care plan dated 05/10/19 revealed Resident #38 required extensive assistants with showering. Record review of the shower schedule revealed Resident #38 was to receive showers on Tuesdays and Fridays. Record review of Point of Care (POC) documentation for April, May, and June 2023 revealed Resident #38 received a shower/bath on 04/06/23, 04/13/23, 04/20, 04/24/23, 04/27/23, 05/04/23, 05/08/23, 05/11/23, 05/15/23, 06/01/23 and 06/12/23. Record review of POC revealed no further documentation of Resident #38 receiving a shower or bath. Observation on 06/15/23 at 12:37 P.M. revealed Resident #38 ambulating up the hall independently. Resident #38 's hair was dishuffled and oily. State tested Nursing Assistant (STNA) #108 verified SR's hair was dischuffled and oily. Interview on 06/15/23 at 4:51 P.M. with DON revealed the facility did not do any paper documentation to confirm when showers for residents were completed. All showers were documented in POC by the STNA ' s on the days the showers were due. Shower documentation would include confirmation the shower was given or if the resident refused the shower. DON confirmed each resident was to receive a minimum of two showers a week. DON confirmed the documentation of showers provided to Resident #38 revealed Resident #38 did not receive two showers a week. DON revealed she was unsure if residents received their showers. 2. Record review for Resident #44 revealed an admitted [DATE]. Diagnosis included chronic obstructive pulmonary disease, muscle weakness, and type two diabetes mellitus. Record review of the quarterly MDS dated [DATE] revealed Resident #44 was cognitively intact, Resident #44 required assistants with activities of daily living. Record review of the care plan for revealed Resident #44 had an activity of daily living self-care performance deficit. Interventions included Resident #44 required extensive staff assistants of one with bathing. Record review of the shower schedule revealed Resident #44 was to receive baths/showers on Mondays and Thursdays. Interview on 06/15/23 at 10:00 A.M. with Resident #44 revealed her concern that she did not receive her showers or baths two times a week. Resident #44 revealed she never refused the showers or baths; staff did not have time to give them. Resident #44 had oily hair. Record review of POC documentation for April, May, and June 2023 revealed Resident #44 received a shower/bath on 04/03/23, 04/17/23, 05/04/23, and 05/15/23. Record review of POC revealed no further documentation of Resident #44 receiving a shower or bath. Interview on 06/15/23 at 4:51 P.M. with DON confirmed the documentation of showers for Resident #44 revealed Resident #44 had no further documentation to confirm Resident #44 received or refused the scheduled showers. Record review of the Grievance log dated 05/16/23 revealed Resident #44 ' s grievance statement included, I am not getting my showers. I am on Monday and Thursday mornings. No one is offering them. Even when I ask, I get ignored. Actions taken included staff training on 05/16/23. 3. Record review for Resident #6 revealed and admitted [DATE]. Diagnosis included impaired mobility and muscle weakness. Record review of the quarterly MDS dated [DATE] for Resident #6 revealed Resident #6 had severe cognitive impairment. Resident #6 required total dependence with bathing. Record review of the care plan dated 6/5/23 for Resident #6 revealed Resident #6 had an activity of daily living self-care performance deficit. Interventions included Resident #6 required assistants with personal hygiene. Record review of the shower schedule for Resident #6 revealed Resident #6 was to receive showers on Mondays and Thursdays. Record review of POC documentation for April, May, and June 2023 revealed Resident #6 received a shower/bath on 04/06/23, 04/13/23, 04/20/23, 04/24/23, 04/27/23, 05/01/23, 05/04/23, 05/11/23, 06/12/23, and 06/15/23. Record review of POC revealed no further documentation of Resident #6 receiving a shower or bath. Interview and observation on 06/15/23 at 12:56 P.M. with Resident #6 had thick, unkept whiskers and oily hair. Resident #6 revealed he wanted showered and shaved and when he asked staff, they would tell him they would get to him when they can. Resident #6 revealed he has not had a shower in a long time. State tested Nursing Assistant (STNA) #108 confirmed Resident #6 had thick, unkept whiskers and oily hair. STNA #108 revealed she was unsure when Resident #6 ' s showers were due. Interview on 06/15/23 at 3:31 P.M. with Administrator revealed there were also clusters of complaints of residents not receiving their showers. Education was provided. Interview on 06/15/23 at 4:51 P.M. with DON confirmed the documentation of showers in POC for Resident #6 revealed Resident #6 had no further documentation to confirm Resident #6 received or refused the scheduled showers. Review of Resident Council meeting minutes dated 04/18/23 revealed resident showers were not consistent. Additional review of Resident Council minutes dated 05/09/23 again revealed residents showers were not consistent. The following deficiency is based on incidental findings discovered during the course of the complaint investigation.

Based on observation, interview and record review, the facility failed to assess one resident, Resident #44's blood sugar prior to the breakfast meal. This affected one resident, Resident #44 of two residents reviewed for assessment of blood sugars. The facility census was 45. Findings include: Record review for Resident #44 revealed an admitted [DATE]. Diagnosis included type two diabetes mellitus. Record review of the quarterly MDS dated [DATE] revealed Resident #44 was cognitively intact and received injections. Record review of the physician orders for Resident #44 for June 2023 revealed Resident #44 was to receive insulin lispro 100 units per milliliter (ml) inject 10 units subcutaneously before meals for glucose control. Medication was scheduled to be administered at 8:30 A.M. Additional orders included insulin lispro 100 units per ml inject as per sliding scale. The sliding scale included if the blood sugar was 301 to 350, give eight units subcutaneously before meals. Observation on 06/15/23 at 10:06 A.M. revealed Registered Nurse (RN) #109 assessed Resident #44's blood sugar via a glucometer. Resident #44's blood sugar was 341. RN #109 confirmed Resident #44 had eaten breakfast at approximately 8:30 A.M. Observation revealed RN #109 administered 18 units of lispro insulin 100 units per ml to Resident #44. RN #109 confirmed the lispro insulin total included 10 units for the A.M. dose with an additional eight units per the sliding scale to equal a total of 18 units. RN #109 confirmed she assessed the blood sugar after the meal (greater than an hour) and administered the sliding scale insulin according to the blood sugar results that were assessed after the meal. RN #109 revealed she got behind on her medications due to needing to send a resident to the hospital. RN #109 confirmed there were management nurses available to assist if needed but she did not ask. RN #109 confirmed the blood sugar assessment and insulin administration should have been completed before Resident #44 had her breakfast. Interview on 06/15/23 at 10:10 A.M. with Resident #44 revealed she ate a peanut butter and jelly sandwich with juice and coffee and cream for breakfast earlier. Resident #44 revealed sometimes the nurses check her blood sugar before breakfast and sometimes after. Interview on 06/15/23 at 4:51 P.M. with the Director of Nursing (DON) revealed if a nurse was unable to assess the blood sugar before the meal and a resident was receiving a sliding scale insulin, then the nurse should call the physician to determine how much insulin should be given for that dose due to the blood sugar being assessed after the meal and not prior. The following deficiency is based on incidental findings discovered during the course of the complaint investigation.

Based on closed record review, hospital record review, Total Parenteral Nutrition (TPN) Team documentation and interview, the facility failed to develop and implement an effective discharge plan for Resident #30 to ensure total parental nutrition (TPN), a specialized formula given through the vein which provides most of the nutrients the body needs was ordered/provided and a home health infusion nurse was arranged for home care following the resident's discharge home from the facility on 01/19/23. Actual Harm occurred on 01/22/23 when Resident #30 presented to the emergency room with signs of hypovolemic shock (volume depletion) after the facility failed to arrange for home going TPN including the coordination of pharmacy services and a home health infusion nurse at the time of discharge from the facility. Upon discharge, the facility provided enough TPN to administer through 01/21/23 in the A.M. Resident #30 was hospitalized from 01/22/23 through 02/01/23. This affected one (Resident #30) of three residents reviewed for discharge/transfer. The facility census was 29. Findings include: Review of the closed medical record for Resident #30 revealed an admitted [DATE] post hospitalization for malnutrition. Diagnoses included severe protein malnutrition, disorder of protein plasma metabolism, nutritional anemia, Crohn's disease (chronic inflammatory bowel disease), gastroesophageal reflux disease without esophagitis, generalized anxiety, major depressive disorder, ileostomy (small intestine is diverted through an opening in the abdomen) and fistula of the intestines. The resident was admitted with TPN orders and treatment. The current TPN order details dated 12/24/22 revealed TPN was to be on (infuse) for 12 hours and be off 12 hours. On Monday, Wednesday and Friday Resident #30 received lipid TPN (provides essential fatty acids) at the same rate. Review of the Admission Minimum Data Set (MDS) 3.0 assessment for Resident #30, dated 12/30/22, revealed intact cognition. Resident #30 required extensive assist of two for bed mobility, transfer, and extensive assist of one for walking in room. Resident #30 weighed 117 pounds with an unknown weight loss or gain. Resident #30 received parental intravenous (IV) therapy with 51 percent or more of daily calories being received through IV. Review of a service note dated 01/12/23 timed 4:26 P.M. revealed Resident #30 plans regarding home health care were to include transportation and home delivery of TPN and other supplies necessary for returning home safely. Date proposed by Resident #30 was 01/18/23. The note indicated the discharge plan of care evaluation was initiated. Review of a nurse note dated 01/17/23 and timed 1:58 P.M. revealed TPN and ostomy self-care at home was reviewed. Resident #30 verbalized step by step the process of each without any errors in steps. Resident #30 verbalized that she would be returning home with home health services. The note indicated pharmacy was called for written TPN orders and extra TPN. Pharmacy representative stated there would be extra TPN in the tote delivered that night. The note indicated no other concerns at that time. Review of notes provided by the nutritional support team of Cleveland Clinic revealed on 01/17/23 at 3:03 PM., Dietitian #43 was notified by Registered Nurse (RN) #44 the patient (Resident #30) completed teaching and signed a patient agreement. Patient wanted to discharge 01/18/23 from the skilled facility. The noted indicated no information received regarding plans for home infusion pharmacy and home care and no records received from facility. Call made to the facility where patient resided and spoke with case manager (Social Services [SS] #42). The notes further indicated SS #42 had never completed a TPN discharge and was unsure of process. Patient had not been set up with a home infusion pharmacy, but SS #42 was working on setting up home care. Discussed patient first needed to be accepted by a home infusion pharmacy, benefits run, and out-of-pocket cost determined. Examples of home infusion pharmacies in town with contact information were provided. The notes indicated once the patient had been accepted by home infusion pharmacy they should be updated. A request for clinical notes, most recent TPN formula and most recent labs be sent to the clinic to review. Once those were reviewed and patient accepted by a home health care agency and home infusion pharmacy, the nutritional support team would send an order to start home parental nutrition at discharge. Recommendation indicated awaiting documentation from skilled facility including clinic notes labs and TPN formula. Awaiting confirmation, patient accepted by home infusion pharmacy and home care nursing. Review of a 01/17/23 fax sent at 5:53 P.M. to Doctor #41, at the All TPN Team, reflected a 12/22/22 Parenteral Nutrition Progress Note from the Nutritional Support Team included Resident #30 planned to discharge 12/23/22 to a skilled facility. After discharge from skilled facility Doctor #41 would take over TPN management at the home. Review of a note from the Digestive clinic authored by Dietitian #40 dated 01/18/23 and timed 10:22 A.M. revealed receipt of skilled facility information including labs, notes from inpatient stay, and partial formula. Return call to skilled facility to obtain the remaining vital information prior to resuming parenteral nutrition orders. A detailed message was left with SS #42 requesting full TPN formula that included volume and hours to be infused as well as which pharmacy and health home care would be servicing, to be faxed as soon as possible. Awaiting remaining information prior to sending orders. Review of a nurse note dated 01/18/23 timed 12:46 P.M. revealed the author spoke with the provider regarding upcoming discharge orders. Provider approved the release of all pain medications to Resident #30 from the facility at the time of discharge. The prescription for pain medications would need to be acquired from the provider of the resident's choice upon discharge. Education was provided to the resident. Resident verbalized understanding. Review of a fax dated 01/18/23 timed 6:23 P.M. to the All TPN Team revealed the fax included the current TPN formula and titration rate. Review of a note from the Home Nutritional Support Service dated 01/19/23 timed 10:05 A.M. revealed the TPN formula received via email continuing same volume as inpatient. Updated to database for reference. The noted indicated still no update from skilled facility on accepting home health care and infusion pharmacy despite home nutritional support request times three. Call to social worker at skilled facility sent to voicemail. Again, left detailed voice message, requesting a call back to confirm pharmacy, home health care and date of discharge. Recommendation indicated awaiting information to send parental nutrition and standing orders. Review of nurse note dated 01/19/23 timed 12:23 P.M. revealed Resident #30 was scheduled for discharge today. TPN would remain running for the scheduled time until completion and/or discharge time; which ever came first. The note indicated would be discharging with TPN and TPN supplies. Resident was tolerating TPN well. Review of a nurse note dated 01/19/23 timed 3:40 P.M. revealed Resident #30 was discharged at 2:00 P.M. Resident #30 took TPN, pump, and medications including narcotics. Medication education was provided and resident confirmed she understood what medications were for and how to properly administer them. Resident #30 left with her sister and no assistive device was used. Review of the Post Discharge Plan of Care/Recapitulation of Stay Plan and Summary initiated 01/17/23 revealed no home health at this time. Doctor aware and agreed for safe discharge to home as resident was with TPN, wound and ostomy care prior to this stay and felt she was safe without home health. Resident #30 supplied with information for ordering future TPN and ostomy/wound supplies from ostomy specialist appointment. The note included Resident #30 reported she would independently order her supplies. All on hand supplies for ostomy, wounds and TPN would be sent home with Resident #30. Other services post discharge to be determined with primary care provider. Pharmacy preference Cleveland Clinic. Resident would complete TPN infusions as ordered following correct steps. Resident would maintain at an acceptable level of pain. Resident #30 would maintain ostomy/fistula care without adverse effects. Nutritional needs included regular diet, regular texture and thin consistency and needed parenteral/IV feeding. TPN orders printed and given to Resident #30 at discharge. TPN formulary orders faxed to the Cleveland Clinic pharmacy. Review of a note authored by Dietitian #40 dated 01/20/23 timed 1:05 P.M. revealed no return call from skilled facility. Called again to confirm date of discharge, pharmacy, and home health care. Social worker not in today. Administrator stated Resident #30 already discharged . Transferred call to Director of Nursing. No answer. Left detailed message requesting update and plan of care from discharge as soon as possible as their team had not yet sent orders. Review of a note authored by Dietician #41 dated 01/20/23 timed 4:32 P.M. revealed patient return call. Resident #30 said she left the skilled nursing facility yesterday, 01/19/22. Skilled facility sent her with two TPN bags for the weekend as well as flushes. Resident #30 said she did not have a pharmacy or home health care set up and would need TPN after the weekend. Recommendation indicated would need to follow up Monday if skilled facility returned call with information, otherwise would likely need to send patient to emergency room to have TPN arrangements set up. Review of a nurse note dated 01/21/23 at 4:38 P.M. revealed the nurse called the facility pharmacy regarding Resident #30's TPN. The nurse was informed the pharmacy filled Resident #30's order on the 17th and next refill would have been the 20th but Resident #30 was already discharged by that date. Review of a nurse note dated 01/22/23 at 8:33 A.M. revealed on 01/17/23 the pharmacy sent a total of three bags of TPN: one bag of non-lipid TPN that was to be infused Thursday (01/19/23) and two bags of Lipid containing TPN for Wednesday (01/18/23) and Friday (01/20/23). According to the nurse's note related to the pharmacy call, Resident #30 had enough TPN to last through Friday (01/20/23). If she infused the TPN at night she would have finished what she took home with her Saturday morning (01/21/23) which would be consistent with Resident #30 calling the facility Saturday asking if there were more bags of TPN there for her. Review of note authored by Dietician #45 dated 01/23/23 timed 9:23 A.M. revealed Resident #30 was admitted to the hospital from the emergency room yesterday (01/22/23). Recommendation indicated awaiting hospital discharge and home health care agencies to be arranged for a safe discharge. Review of the hospital discharge summary dated 02/01/23 revealed Resident #30 presented to the emergency room with signs of hypovolemic shock. Resident #30 presented with dizziness hypertension, tachycardia, acute kidney injury. History was most consistent with hypokalemia (low potassium) from not getting TPN and fluids following discharge from skilled facility. Resident #30 also had shortness of breath for several months which could be the result of weakness and deconditioning tear. Also has a history of Crohn's disease and TPN dependent, having multiple abdominal surgeries, multiple fistulas, and chronic abdominal pain. Elevated, alkaline phosphates, and liver function test, acute kidney injury pre-renal poor intake and hypotension, hyponatremia, hypovolemia due to poor oral intake and absence of TPN the last few days. The resident was also assessed to have a deep vein thrombosis (DVT) in upper extremity. Interview 02/17/23 at 10:24 A.M. with All TPN Team Dietician #40 from the Cleveland Digestive Clinic revealed Resident #30 was discharged from the skilled facility without a plan and was re-hospitalized three days after she was discharged with lightheadedness, generalized weakness, hypovolemic shock, and tachycardia. Dietician #40 included the clinic repeatedly reached out to the facility, left voicemails and verbal directions of the clinic needing current TPN orders, laboratory test and what home health agency and pharmacy Resident #30 was going to use. Dietician #40 revealed she called SS #42 leaving a voicemail without a return call. The initial fax she received from the skilled facility had partial information. The second fax contained the TPN order. However, the clinic was not informed of what pharmacy to send the TPN to and what home health agency Resident #30 would be using for an infusion nurse. Dietician #41 included Resident #30 had been on TPN for two years but was new to the Digestive Clinic as of December of 2022 due to moving to Ohio. Interview 02/17/23 at 1:49 P.M. with SS #42 revealed this was her first social services position and she was new to the job. SS #42 had never set up home health and stated she called every facility in the rolodex. It did not occur to SS #42 to call the Digestive clinic to inquire about providers with an infusion nurse. Follow up interview 02/17/23 at 2:38 P.M. with SS #42 revealed Resident #30 had a goal to go home before her birthday. The facility staff did not feel she was ready to go home. SS #42 attempted to find home health for Resident #30 but was unable to find a home health nurse for TPN and she told Resident #30 this. The Cleveland Clinic SS #42 and she had several discussions. On 01/18/23 SS #42 spoke to Dietician #40 from the TPN team at the Cleveland Clinic about setting up the pharmacy for the resident's TPN. They decided on a provider. Dietician #40 asked for TPN formulary, recent labs, and clinical notes. SS #42 faxed the TPN formula, labs, and progress notes. SS #42 did not hear back from them that night and was off sick the next two days. SS #42 sent a fax earlier and Dietician #40 called indicating it was not complete and SS #42 sent a second fax on 01/18/23 at 6:18 P.M. When SS #42 returned to work on Monday (01/23/23) she had a message from someone else from the TPN team indicating they thought Resident #30 was discharged and they needed to know what pharmacy she chose. SS #42 called them Monday (01/23/23) and left multiple messages. Someone called back and said Resident #30 had gone back to the Cleveland Clinic (hospital). SS #42 explained to them she thought they were connected to the pharmacy and that they would call and make the needed arrangements with the pharmacy. SS #42 said she was not told she needed to find a home infusion nurse; Resident #30 told SS #42 she had a home infusion nurse. When SS #42 told Resident #30 she could not find a home infusion nurse she was very upset and wanted to go home. SS #42 did not speak to a doctor regarding the TPN and discharge. SS #42 did not call the TPN team to tell them she could not find a home health infusionist or a pharmacy to provide the TPN. Interview 02/17/23 at 5:20 P.M. with the administrator revealed he did not know if he received a call regarding Resident #30. Interview 02/17/23 at 5:26 P.M. with the Director of Nursing (DON) revealed she did not have a message on her phone from the Digestive Clinic. The DON said the day Resident #30 went home her TPN was started at the facility at 9:00 A.M. and ran until she left at 2:00 P.M. The DON indicated Resident #30 infused the TPN 12 hours at night when home. Resident #30 called the facility on 01/21/23 asking if there were any more bags of TPN at the facility for her. The DON referred to the 01/22/23 nurse note timed 8:33 A.M. indicating on 01/17/23 the pharmacy sent a total of three bags of TPN. One bag of non-lipid TPN that was to be infused that Thursday (01/19/23) and two bags of Lipid containing TPN for that Wednesday (01/18/23) and Friday (01/20/23). The DON verified Resident #30 was readmitted to the hospital when she did not have any TPN to infuse at home. This deficiency represents non-compliance investigated under Complaint Number OH00139912.

Based on record review, policy review and staff interview, the facility failed to develop a comprehensive discharge summary. This affected one (Resident #31) of three residents reviewed for a safe discharge. The census was 29. Findings include: Review of Resident #31's record revealed a 08/23/22 admission. Diagnoses included acute respiratory failure with hypoxia, hypertension, type two diabetes, malignant neoplasm of prostrate, malignant neoplasm of intra abdominal lymph nodes, severe protein malnutrition, neuromuscular dysfunction of bladder, age related osteoporosis, hemiplegia and hemiparesis following cerebral infarction, acute kidney failure, and vitamin D deficiency. Review of the Quarterly Minimum Data Set 3.0 assessment for Resident #31, dated 01/03/23, revealed Resident #31 had intact cognition. Resident #31 required extensive assist of two for bed mobility and transfer and did not walk. Resident #31 required extensive assistance of one for dressing and eating, extensive assistance of two for toilet use and personal hygiene and was totally dependent of two for bathing. Resident #31 was always incontinent of bowel and bladder. Resident #31 received physical therapy. Review of the nurse notes dated 01/10/23 Revealed Resident #31 was discharged to another long term care facility utilizing the receiving facility's transportation. All possessions were taken with him at discharge. A face sheet and medication list were sent to the receiving facility. Further review of the medical record revealed no evidence of a Post Discharge Plan of Care/Recapitulation of Stay Plan and Summary. Interview 02/17/23 at 5:58 P.M. the Director of Nursing (DON) verified a comprehensive discharge recapitulation was not completed. Review of the facility's Transfer and Discharge policy revised 09/09/23 included the when the facility anticipated discharge, a resident must have a discharge summary that included, but not limited to a recapitulation of the resident stay that included but was not limited to diagnosis, course of illness, treatment or therapy, and pertinent lab, radiology, and consultation results. A final summary of the resident status at the time of the discharge was to be available for release to authorized persons and agencies with consent of the resident or resident representative. This deficiency represents non-compliance investigated under Complaint Number OH00139912.

Based on observation, record review and interview the facility failed to ensure antibiotics were ordered and administered to Resident #16 in a timely manner to treat suspected osteomyelitis (bone infection). Actual Harm occurred on 12/08/22 when Resident #16 was admitted to the hospital with a diagnosis of sepsis (blood infection) related to a wound to the left heel. Physician order for the antibiotic, doxycycline was not obtained as recommended to treat suspected osteomyelitis contributing to the hospitalization . This affected one resident (#16) of one resident reviewed for wounds. The facility identified one resident as having wounds, Resident #16. The facility census was 34. Findings include: 1. Review of Resident #16's medical records revealed an admitted [DATE] with diagnoses including non pressure chronic ulcer of right foot, peripheral vascular disease (PVD) and diabetes. Resident #16 was admitted with two unstageable pressure ulcers (areas were not identified). Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/25/22 revealed Resident #16 had impaired cognition, required extensive assistance with bed mobility, transfers, toileting and personal hygiene, and was incontinent of bowel and bladder. Review of physician's orders from 09/19/22 through 10/17/22 revealed Resident #16 was ordered the antibiotic, doxycycline 100 milligrams (mg) twice a day for 28 days for wound infection. Review of Resident #16's physician orders for November 2022 revealed an order to cleanse left heel with normal saline, pack with Dakins (antiseptic) soaked gauze, cover with absorbent dressing and wrap with Kerlix daily and as needed, and paint right heel with Betadine (antiseptic) and apply absorbent dressing every Monday, Wednesday and Friday. Review of a skin and wound assessment for Resident #16 dated 11/18/22 revealed the wound nurse practitioner suspected osteomyelitis and a new order to consult with the house physician to obtain imaging was given. Review of the wound care progress note/wound evaluation for Resident #16 dated 11/18/22 revealed an order for calcium alginate with silver (antimicrobial wound dressing to prevent infection) to the right heel, cover with an absorbent dressing and gauze daily and as needed. The left heel wound was ordered to be packed with Dakins soaked gauze, cover with an absorbent dressing and wrap with gauze daily and as needed. Review of Resident #16's progress note dated 11/18/22 authored by the Assistant Director of Nursing (ADON) revealed the wound nurse practitioner suspected osteomyelitis and to consult with house physician to obtain imaging. Review of the wound care progress note/wound evaluation authored by the wound nurse practitioner, for Resident #16, dated 11/23/22 revealed to continue with calcium alginate to right heel, cover with absorbent dressing and gauze daily and as needed. Left heel wound was to be packed with Dakins soaked gauze twice daily. The evaluation indicated the wound had an odor and thick drainage. Doxycycline 100 mg was recommended. The note indicated to notify the house physician of recommendations for antibiotic therapy. Review of the physician's orders revealed no order for doxycycline on 11/23/22. Review of the wound care progress note/wound evaluation for Resident #16, dated 11/30/22 revealed to discontinue the calcium alginate to right heel and begin packing the wound with Dakins soaked gauze twice daily. Wound was noted to be odorous. Left heel wound continued to be packed with Dakins soaked gauze twice daily. The note stated to extend the doxycycline 100 mg for an additional 10 days, and might require diagnostic imaging at the discretion of the house physician due to the high risk of osteomyelitis. The note indicated nursing to notify the house physician. Further review of Resident #16's physician orders revealed an order for Doxycycline 100 mg on 12/01/22 through 12/10/22 twice a day for infection. Interview on 12/06/22 at 9:38 A.M. with the Director of Nursing (DON) revealed although a recommendation for doxycycline was made on 11/23/22 there was no physician order in place for the antibiotic until she entered the order on 12/01/22. Observation of wound care on 12/07/22 at 10:55 A.M. for Resident #16 with the DON and LPN #433 revealed wounds to the resident's bilateral heels had a strong odor and thick yellowish drainage coming from the wounds. Interview on 12/07/22 at 11:22 A.M. with the DON revealed she received the wound progress notes and evaluations weekly and stated she must have missed the recommended order for antibiotics. The DON confirmed the antibiotics recommended on 11/23/22 were ordered on 12/01/22. Review of the progress note, dated 12/07/22 revealed x-ray results showed Resident #16 had osteomyelitis of the left heel. The note indicated the nurse practitioner was notified and Resident #16 was to be transported to the hospital. Review of the progress note dated 12/08/22 revealed Resident #16 was admitted to the hospital with sepsis (blood infection).

Based on observation, record review and interview the facility failed to ensure residents received adequate, necessary and timely care and treatment to meet their total care needs. The facility failed to ensure antibiotics and x-rays were completed as ordered for Resident #16, failed to ensure monthly weights were completed for Resident #1, and failed to ensure physician orders were in place for blood glucose monitoring of Resident #84. Actual Harm occurred on 12/08/22 when Resident #16, who was cognitively impaired and required staff assistance for activities of daily living was admitted to the hospital with a diagnosis of sepsis (blood infection) related to a wound to the left heel. Physician's orders for the antibiotic, Doxycycline and imaging to rule out osteomyelitis were not completed as ordered contributing to the hospitalization . This affected one resident (#16) of one resident reviewed for wounds and two residents (#1 and #84) of 14 sampled residents. The facility identified one resident as having wounds, Resident #16. The facility census was 34. Findings include: 1. Review of Resident #16's medical records revealed an admitted [DATE] with diagnoses including non pressure chronic ulcer of right foot, peripheral vascular disease (PVD) and diabetes. Record review revealed Resident #16 was admitted with two unstageable pressure ulcers (areas were not identified). Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/25/22 revealed Resident #16 had impaired cognition, required extensive assistance with bed mobility, transfers, toileting and personal hygiene, and was incontinent of bowel and bladder. Review of the care plan dated 10/25/22 revealed Resident #16 was at risk for skin impairment related to decreased mobility and muscle weakness. Interventions included weekly head to toe skin assessments and observe wound dressing frequently to ensure intact. Review of physician's orders from 09/19/22 through 10/17/22 revealed Resident #16 was ordered the antibiotic, Doxycycline 100 milligrams (mg) twice a day for 28 days for wound infection. Review of Resident #16's physician orders for November 2022 revealed an order to cleanse left heel with normal saline, pack with Dakins (antiseptic) soaked gauze, cover with absorbent dressing and wrap with Kerlix daily and as needed, and paint right heel with Betadine (antiseptic) and apply absorbent dressing every Monday, Wednesday and Friday. Review of a skin and wound assessment for Resident #16 dated 11/18/22 revealed the wound nurse practitioner suspected osteomyelitis (bone infection) and a new order to consult with the house physician to obtain imaging was given. Review of the wound care progress note/wound evaluation for Resident #16 dated 11/18/22 revealed an order for calcium alginate with silver (antimicrobial wound dressing to prevent infection) to the right heel, cover with an absorbent dressing and gauze daily and as needed. The left heel wound was ordered to be packed with Dakins soaked gauze, cover with an absorbent dressing and wrap with gauze daily and as needed. Review of Resident #16's progress note dated 11/18/22 authored by the Assistant Director of Nursing (ADON) revealed the wound nurse practitioner suspected osteomyelitis and to consult with house physician to obtain imaging. Review of the wound care progress note/wound evaluation authored by the wound nurse practitioner, for Resident #16, dated 11/23/22 revealed to continue with calcium alginate to right heel, cover with absorbent dressing and gauze daily and as needed. Left heel wound was to be packed with Dakins soaked gauze twice daily. The evaluation indicated the wound had an odor and thick drainage. Doxycycline (an antibiotic) 100 mg was recommended. The note indicated to notify the house physician of recommendations for antibiotic therapy. Review of the physician's orders revealed no order for Doxycycline on 11/23/22. Review of the wound care progress note/wound evaluation for Resident #16, dated 11/30/22 revealed to discontinue the calcium alginate to right heel and begin packing the wound with Dakins soaked gauze twice daily. Wound was noted to be odorous. Left heel wound continued to be packed with Dakins soaked gauze twice daily. The note stated to extend the Doxycycline 100 mg for an additional 10 days, and might require diagnostic imaging at the discretion of the house physician due to the high risk of osteomyelitis. The note indicated nursing to notify the house physician. Review of physician's orders revealed no orders for imaging on 11/30/22. However, review of Resident #16's progress note, dated 11/30/22 revealed an order was placed with an x-ray company and a confirmation number and contact person at the x-ray company were listed. Further review of Resident #16's physician orders revealed an order for Doxycycline 100 mg on 12/01/22 through 12/10/22 twice a day for infection. Interview on 12/05/22 at 2:45 P.M. with the Director of Nursing (DON) revealed Resident #16's orders did not contain an order for an imaging. The DON stated she would need to check the resident's chart to see if an x-ray had been performed. Review of Resident #16's physician's orders revealed following the interview with the DON, on 12/06/22 an order was obtained for an x-ray of bilateral feet. Review of Resident #16's progress note, dated 12/06/22 revealed the facility contacted the x-ray company and was informed the company did not have an x-ray tech available and would send one on 12/07/22. Interview on 12/06/22 at 9:33 A.M. with Licensed Practical Nurse (LPN) #446 revealed she was asked by the DON to place orders for an x-ray for Resident #16. LPN #446 stated she worked for an agency and was not aware of the situation regarding Resident #16's wounds/x-rays. Interview on 12/06/22 at 9:38 A.M. with the DON revealed the DON was unable to locate an order for the x-ray and the DON asked LPN #446 to place orders for the x-ray to be completed. The DON further stated there was no physician order in place for the antibiotic until she entered the order on 12/01/22. Interview on 12/06/22 at 12:08 P.M. with the Assistant Director of Nursing (ADON) revealed the ADON received verbal orders for Resident #16 on 11/18/22 to obtain imaging and consult with the house physician. The ADON was unable to state why the orders were not completed or in the computer system. Observation of wound care on 12/07/22 at 10:55 A.M. for Resident #16 with the DON and LPN #433 revealed wounds to the resident's bilateral heels had a strong odor and thick yellowish drainage coming from the wounds. Interview on 12/07/22 at 11:22 A.M. with the DON revealed she received the wound progress notes and evaluations weekly and stated she must have missed the recommended orders for the x-ray and the antibiotics. The DON confirmed the recommended antibiotics were ordered on 12/01/22 and the x-ray would be completed on 12/07/22. Review of the progress note, dated 12/07/22 revealed the x-ray results showed Resident #16 had osteomyelitis of the left heel. The note indicated the nurse practitioner was notified and Resident #16 was to be transported to the hospital. Review of the progress note dated 12/08/22 revealed Resident #16 was admitted to the hospital with sepsis (blood infection). 2. Review of the medical record for Resident #1 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, dementia, acute kidney failure and moderate protein-calorie malnutrition. Review of the MDS quarterly assessment dated [DATE] revealed Resident #1 had severe cognitive impairment and required supervision with set up for eating and limited assistance of one staff for walking in his room and on the unit. Further review of Resident #1's medical record revealed the last recorded weight was on 09/23/22 and no weight refusals were documented in the nursing progress notes or under the monthly weight task listed in the task bar. Review of Resident #1's current physician orders for December 2022 did not reveal an order for monthly weights. Review of the nutrition assessment completed by Registered Dietitian (RD) #444 on 12/05/22 revealed no new weights since 09/23/22 to review and weights were usually stable. Interview on 12/12/22 at 9:30 A.M. with Registered Dietitian (RD) #444 revealed residents should be weighed monthly and if a resident refused to be weighed it should be documented in the medical record. Interview on 12/12/22 at 10:15 A.M. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed Resident #1 had not been weighed between 09/23/22 and 12/06/22. Review of the 07/14/21 revised facility policy titled, Weight Management revealed weekly weights would be completed by the 10 th of each month and documented in the medical record. The Dietary Manager and/or Registered Dietitian would communicate weight changes to the interdisciplinary team, attending physician and resident responsible party and be documented in the medical record. 3. Record review of Resident #84 revealed he was admitted to the facility 11/19/22 and had diagnoses including cognitive communication deficit, hyperkalemia, and type 2 diabetes. Review of Resident #84's hospital discharge instructions dated 11/18/22 revealed Resident #84 was to receive blood glucose checks with meals and at bedtime. Review of Resident #84's physician orders revealed no current or previous orders for blood sugar monitoring. Review of the resident's vital signs records revealed no documented blood sugar checks for the resident. Review of Resident #84's progress notes and physician assessments revealed no explanation as to why the hospital instructions were not carried out. Interview with the Director of Nursing on 12/07/22 at 4:16 P.M. confirmed the above findings and lack of blood glucose monitoring for Resident #84 who had a diagnoses of type 2 diabetes.

Based on observation, interview, and facility policy review, the facility failed to maintain a clean, sanitary kitchen area, ensure foods were stored in a clean and sanitary manner to prevent contamination and food borne illness, and ensure expired products were discarded. This affected all 34 residents residing at the facility receiving meals. Findings included: 1. Observation on [DATE] at 8:10 A.M. during tour of the kitchen with Dietary Manager #410 revealed heavily soiled floors throughout the kitchen. The cold air return vent on the opposite wall of the dish machine revealed a heavily soiled vent on the wall with thickened black dust on the grates with peeling paint. Mold that was black in color was visible on the ceiling above the dish machine, and the exhaust pipe from the dish machine to the outside wall had mold and peeling paint over the area where clean dishes were discharged from the dish machine. A light switch with metal tubing covering the electrical wires going from the wall switch towards the ceiling had peeling paint above the clean dish lane where clean trays of dishes were located. Observation of the reach in refrigerators on [DATE] at 8:17 AM with Dietary Manager #410 revealed an eight pound container of macaroni salad opened on [DATE] with a use by date of [DATE], an eight pound container of potato salad with a opened date of [DATE] and a use by date of [DATE], a two pound package of honey ham slices with an opened date of [DATE] and a use by date of [DATE], a five pound package of shredded mozzarella cheese with an opened date of [DATE] and a use by date of [DATE], a two pound package of roast beef slices with an opened date of [DATE] and use by date of [DATE], a five pound bag of shredded cheddar cheese with an open date of [DATE] and a use by date of [DATE], a two pound package of sliced Swiss cheese with an opened date of [DATE] and a use by date of [DATE], a five pound open container of cottage cheese with an opened date of [DATE] and a use by date of [DATE], an open undated package of pound cake with no date of opening or use by date listed. Observation in the dry storage area revealed an opened five-pound package of cornmeal mix with an opened date of [DATE] and a use by date of [DATE], a 12 pack of hamburger buns with a date of [DATE] stamped on them. Dietary Manager #410 stated the hamburger buns came frozen and were thawed recently but was unsure of exact date and confirmed there was not a use by date listed on the package. Dietary Manager #410 confirmed all the above items listed. Dietary Manager #410 stated the floors were cleaned as often as they were able to with the current staffing, and stated she was unsure the last date the floor was swept or mopped. On [DATE] at 9:35 A.M. Dietary Manager #410 provided a copy of a paper hanging in the kitchen that stated, Clean, Clean and Clean! Please and thank you! and confirmed she did not have any written proof of cleaning schedules having been completed since she started in [DATE]. Review of the undated Dietary Aide A.M. Duties per shift form hanging in the kitchen provided by Dietary Manager #410 revealed each shift refrigerators and freezers were to be wiped down for cleanliness, expired or outdated items were to be thrown out and the entire kitchen was to be swept and mopped. Review of facility form titled Use by Date Storage Chart dated [DATE] revealed leftover foods were to be discarded after three days including the preparation day. Deli meats were to be disposed of after being opened for seven days. Interview on [DATE] at 3:25 P.M. with the Administrator revealed he was aware of the peeling paint in the kitchen. The Administrator stated he had gotten a quote from a painting company a couple of months ago, had submitted the quote to the corporate office for approval and had not received any further correspondence from the corporate office. Review of the kitchen repair quote submitted by the Administrator revealed a quote for repairs was completed on [DATE]. Review of corporate correspondence related to the kitchen repairs quote revealed request for repairs were submitted by the Administrator to corporate on [DATE]. Scheduling of repairs was authorized by corporate on [DATE] after the interview with the Administrator regarding the kitchen concerns. 2. Observation on [DATE] at 8:21 A.M. during medication administration with Licensed Practical Nurse (LPN) #445 for Resident #21 revealed LPN #445 pouring a cup of thickened cranberry juice that was on top of her medication cart. Observation revealed the cranberry juice had an opened date of [DATE]. The label on the back of the juice bottle indicated to discard the product after 10 days of opening. Interview with LPN #445 at the time of the observation verified the findings.

Based on observation, interview, and record review, the facility failed to ensure residents received scheduled and appropriate activities on the weekend. This affected Residents #7, #21, #22 and #84 and had the potential to affect all 34 residents in the facility. Findings include: Record review of the facility activity calendar revealed on Sunday 12/04/22 the following activities were scheduled: Trivia and coffee at 1:00 P.M., floats and tunes at 2:00 P.M., and word puzzles at 3:00 P.M. This exact schedule was also in place for Sunday 12/11/22 and Sunday 12/18/22. Interview with Resident #22 on 12/04/22 at 9:22 A.M. revealed the facility occasionally had activities on Saturday, otherwise there were no activities over the weekend. Observation of the facility common and activity rooms on 12/04/22 at 1:27 P.M. revealed no evidence of any organized activities in progress. Two large whiteboards in common rooms had the day's activity schedule prominently posted. Interview with State-tested Nursing Aide #443 on 12/04/22 at 1:37 P.M. revealed she knew of no activity workers currently in the building. Group activities were usually done in the dining room. Observation of the facility common and activity rooms on 12/04/22 at 2:16 P.M. revealed six residents were in common rooms with the television on. Activity Worker #435 was rounding with an ice cream cart offering ice cream to residents at their tables and in rooms. An unidentified resident asked her if there would be activities today and she said there would be word puzzles. Observation of the facility common and activity rooms on 12/04/22 at 3:07 P.M. revealed four residents were in the dining room with the television on. Activity Worker #435 was alone in the activity room on the computer. At 3:13 P.M., Activity Worker #435 left the office with several sheets of paper and stopped in five resident rooms offering to give them a word puzzle. She walked past the four residents in the dining room without speaking to them. Interview with Activity Worker #435 on 12/04/22 at 3:20 P.M. revealed the word puzzle was for residents to work on independently. She said no resident wanted to gather for trivia or for floats and tunes, so she delivered ice cream instead. She sometimes made one-to-one visits but had not visited all dependent residents today including Resident #21 and #84. When making rounds for visits or to deliver independent activities, she said she was supposed to skip rooms when the door was closed. She worked approximately four hours every weekend day and would leave today at 3:30 P.M. Interview with Resident #7 on 12/05/22 at 9:11 A.M. revealed no one invited him to any activities Sunday, and he did not know of or attend any. Interview with the wife of Resident #21 on 12/05/22 at 2:15 P.M. revealed she did not see any activities in the facility on weekends. She said staff sometimes left the resident sitting by himself while they took others to activities. Interview with Resident #22 on 12/06/22 at 11:25 A.M. revealed no one invited him to any activities Sunday, and he did not know of or attend any. Review of the activity logs for Resident #84, and #21 revealed no activity was documented for Resident #84 on the weekends of 11/19/22, 11/26/22, or 12/03/22. One-to-one visits were documented as done for Resident #21 on 12/04/22 at 1:40 P.M. The surveyor reviewed the above findings with Activity Director #426 on 12/07/22 at 2:27 P.M., including that one-to-one activities were documented as done for Resident #21 even though interview verified Activity Worker #435 did not do any activities for Resident #21 that day. Activity Director #426 said Activity Worker #435 documented it as done because she saw another staff member talking to the resident. Activity Director #426 said one activity assistant worked on the weekends from approximately 1:00 P.M. until dinnertime. This deficiency represents non-compliance investigated under Complaint Number OH00136408.

Based on observation, record review and interview the facility failed to maintain a medication error rate of less than five percent. The medication error rate was 10.71 percent. Three errors occurred in 28 opportunities for error. This affected two residents (#22 and #36) of five residents observed for medication administration. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 12/04/21 with diagnoses including type II diabetes, hypertension, and kidney transplant. Review of the care plan dated 10/27/22 revealed Resident #22 was at risk for fluctuation of blood sugar levels related to type II diabetes and end stage renal disease. Interventions included to administer medications as ordered and to observe for signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar). Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 had intact cognition and received insulin by injection. Review of the physician's orders dated January 2022 revealed Resident #22 had an order for Novolog flex pen (short acting insulin) to be injected subcutaneous by pen prior to meals. Observation of medication administration on 01/05/23 at 12:15 P.M. revealed Registered Nurse (RN) #100 preparing the Novolog pen by removing the cap, twisting the needle onto the pen, and dialing the pen to administer 14 units of insulin. RN #100 applied gloves, wiped Resident #22's abdomen with alcohol and administered the insulin. RN #100 did not prime the insulin pen prior to dialing the 14 units. 2. Review of the medical record for Resident #36 revealed an admission date of 04/12/22 with diagnoses including type II diabetes, hypertension a high blood pressure, hemiplegia one sided weakness. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #36 had intact cognition and received insulin by injection. Review of the care plan dated 10/04/22 revealed Resident #36 was at risk for fluctuation of blood sugar levels related to type II diabetes. Interventions included to administer medications as ordered and to observe for signs and symptoms of hypoglycemia and hyperglycemia. Review of the physician's orders dated January 2022 revealed Resident #36 had an order for Novolog flex pen (short acting insulin) 10 units to be injected subcutaneous by pen prior to meals. In addition Resident #36 had an order for insulin based on the following sliding scale. For blood blood sugar of 0-150 give no insulin, 151-200 give two units, 201- 250 give four units, 301-350 give eight units and 352-400 give 10 units. Observation of medication administration on 01/05/22 at 12:30 P.M. revealed RN #100 checking Resident #36's blood sugar. Resident #36's blood sugar was 130. RN #100 prepared a Novolog pen to administer ten units by removing the cap for the insulin, twisting the needle onto the pen and dialing ten units of insulin. RN #100 applied gloves, wiped Resident #37's abdomen with alcohol and administered the insulin. RN #100 did not prime the insulin pen prior to dialing in the 10 units. Interview on 01/05/22 at with RN #100 at 1:05 P.M. verified that she did not prime Resident #22's or Resident #36's insulin pens. RN #100 stated she did not know the insulin pens required priming prior to every injection and she primed the pens that morning. Review of the manufacturer's instructions for Novolog pen revealed to prime the pen before each injection. Priming the pen removed air from the needle and cartridge that may have collected during normal use and ensured the pen was working properly. Priming the pen ensured proper dosing. Review of the facility policy titled Medication Administration, dated 09/09/22 revealed the nurse was responsible to read and follow precautionary instructions on the prescription labels. 3. Review of the medical record for Resident #22 revealed an admission date of 12/04/21 with diagnoses including type II diabetes, hypertension, and kidney transplant. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #22 had intact cognition and received insulin by injection. Review of the physician's orders dated January 2022 revealed Resident #22 had an order for metoprolol succinate 50 milligram (mg) extended release tablet. Observation of medication administration on 01/09/23 at 8:10 A.M. revealed RN #100 preparing Resident #22's morning medications including metoprolol succinate. RN #100 crushed the medication tablets including the metoprolol succinate 50 mg extended release tablet and mixed all the crushed tablets with applesauce. RN#100 administered the medications to Resident #22. Interview with RN #100 immediately after the observation revealed she was unaware that metoprolol succinate was an extended-release tablet that should not be crushed. Review of the manufacturer prescribing information revealed metoprolol succinate extended-release tablets were scored and could be divided; however, the whole or half tablet should be swallowed whole and not chewed or crushed. Review of the facility policy titled Medication Administration, dated 09/09/22 revealed to follow safe preparation practices and check the do not crush list before crushing medications. If, necessary, contact the ordering physician for a change to a different route of administration when the medication cannot be crushed.

Based on observation, record review and interview the facility failed to maintain a medication error rate of less than five percent. The medication error rate was 10.71 percent. Three errors occurred in 28 opportunities for error. This affected two residents (#22 and #36) of five residents observed for medication administration. Findings include: 1. Review of the medical record for Resident #22 revealed an admitted [DATE] with diagnoses including type II diabetes, hypertension, and kidney transplant. Review of the care plan dated 10/27/22 revealed Resident #22 was at risk for fluctuation of blood sugar levels related to type II diabetes and end stage renal disease. Interventions included to administer medications as ordered and to observe for signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar). Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 had intact cognition and received insulin by injection. Review of the physician's orders dated January 2022 revealed Resident #22 had an order for Novolog flex pen (short acting insulin) to be injected subcutaneous by pen prior to meals. Observation of medication administration on 01/05/23 at 12:15 P.M. revealed Registered Nurse (RN) #100 preparing the Novolog pen by removing the cap, twisting the needle onto the pen, and dialing the pen to administer 14 units of insulin. RN #100 applied gloves, wiped Resident #22's abdomen with alcohol and administered the insulin. RN #100 did not prime the insulin pen prior to dialing the 14 units. 2. Review of the medical record for Resident #36 revealed an admitted [DATE] with diagnoses including type II diabetes, hypertension a high blood pressure, hemiplegia one sided weakness. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #36 had intact cognition and received insulin by injection. Review of the care plan dated 10/04/22 revealed Resident #36 was at risk for fluctuation of blood sugar levels related to type II diabetes. Interventions included to administer medications as ordered and to observe for signs and symptoms of hypoglycemia and hyperglycemia. Review of the physician's orders dated January 2022 revealed Resident #36 had an order for Novolog flex pen (short acting insulin) 10 units to be injected subcutaneous by pen prior to meals. In addition Resident #36 had an order for insulin based on the following sliding scale. For blood blood sugar of 0-150 give no insulin, 151-200 give two units, 201- 250 give four units, 301-350 give eight units and 352-400 give 10 units. Observation of medication administration on 01/05/22 at 12:30 P.M. revealed RN #100 checking Resident #36's blood sugar. Resident #36's blood sugar was 130. RN #100 prepared a Novolog pen to administer ten units by removing the cap for the insulin, twisting the needle onto the pen and dialing ten units of insulin. RN #100 applied gloves, wiped Resident #37's abdomen with alcohol and administered the insulin. RN #100 did not prime the insulin pen prior to dialing in the 10 units. Interview on 01/05/22 at with RN #100 at 1:05 P.M. verified that she did not prime Resident #22's or Resident #36's insulin pens. RN #100 stated she did not know the insulin pens required priming prior to every injection and she primed the pens that morning. Review of the manufacturer's instructions for Novolog pen revealed to prime the pen before each injection. Priming the pen removed air from the needle and cartridge that may have collected during normal use and ensured the pen was working properly. Priming the pen ensured proper dosing. Review of the facility policy titled Medication Administration, dated 09/09/22 revealed the nurse was responsible to read and follow precautionary instructions on the prescription labels. 3. Review of the medical record for Resident #22 revealed an admitted [DATE] with diagnoses including type II diabetes, hypertension, and kidney transplant. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #22 had intact cognition and received insulin by injection. Review of the physician's orders dated January 2022 revealed Resident #22 had an order for metoprolol succinate 50 milligram (mg) extended release tablet. Observation of medication administration on 01/09/23 at 8:10 A.M. revealed RN #100 preparing Resident #22's morning medications including metoprolol succinate. RN #100 crushed the medication tablets including the metoprolol succinate 50 mg extended release tablet and mixed all the crushed tablets with applesauce. RN#100 administered the medications to Resident #22. Interview with RN #100 immediately after the observation revealed she was unaware that metoprolol succinate was an extended-release tablet that should not be crushed. Review of the manufacturer prescribing information revealed metoprolol succinate extended-release tablets were scored and could be divided; however, the whole or half tablet should be swallowed whole and not chewed or crushed. Review of the facility policy titled Medication Administration, dated 09/09/22 revealed to follow safe preparation practices and check the do not crush list before crushing medications. If, necessary, contact the ordering physician for a change to a different route of administration when the medication cannot be crushed.

Based on interview and record review, the facility failed to ensure resident physicians signed and acted on pharmacy recommendations. This affected four of five (Residents, #1, #7, #12 and #15) residents reviewed for unnecessary medications. The total census was 34. Findings include: 1. Record review of Resident #12 revealed she was admitted [DATE] and had diagnoses including hyperlipidemia, dementia with behavior disturbances, and major depressive disorder. Her medications included Atorvastatin (an anti-hyperlipidemia medication) and 2 milligrams of Aripiprazole (an antipsychotic) daily. Review of resident #12's pharmacy record reviews revealed a consultation report dated 03/08/22 which recommended a lipid panel be drawn on the next convenient lab day and yearly thereafter. The report was signed as accepted on 06/08/22, however her records revealed no evidence the lab was drawn although she had seven blood draws since the time of the order. Another consultation report dated 07/22/22 noted she had received 2 milligrams Aripiprazole daily since her admission and recommended a dose reduction be attempted. The report had no signature indicating it was read by or communicated to the physician. Interview with the Director of Nursing on 12/06/22 at 10:36 A.M. confirmed the above findings. 45442 2. Review of the medical record for Resident #1 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia, schizophrenia, schizoaffective disorder depressive type, acute kidney failure, moderate protein-calorie malnutrition, major depressive disorder, anxiety disorder, psychotic disorder with delusion, epilepsy, and neuroleptic induced parkinsonism. Review of the MDS quarterly assessment dated [DATE] revealed Resident #1 had severe cognitive impairment. Review of pharmacy recommendations for Resident #1 revealed on 04/14/22 as well as 05/09/22 pharmacy recommendations were not signed by the physician, there were no pharmacy reviews presented for 08/22/22 and 09/22/22 and the facility was unable to provide the pharmacy recommendations report for 11/16/22. Interview on 12/12/22 at 7:58 A.M. with the Director of Nursing (DON) confirmed recommendations were not signed for April and May 2022, pharmacy recommendations came to the DON, and she was unable to state what the process was since she had only been at the facility for one month. 3. Review of medical record for Resident #7 revealed an admitted [DATE]. Diagnoses included chronic kidney disease, moderate protein-calorie malnutrition, major depressive disorder, and history of traumatic brain injury. Review of the MDS quarterly assessment dated [DATE] revealed Resident #7 was cognitively intact. Review of physician orders for Resident #1 revealed a 07/24/22 order for Depakote 500 milligrams (mg), one time a day at bedtime for seizures. An order dated 08/24/22 indicated to obtain a renal/Depakote labs. Review of the pharmacy review for Resident #7 revealed on 07/26/22 pharmacy recommendations included valproic acid level to be drawn the next lab day and every six months following. The pharmacy review was not acknowledged or signed by the physician. On 08/17/22 pharmacy recommendations for pantoprazole (heartburn medication) were not acknowledged or signed by the physician, on 09/21/22 the pharmacy recommendations for pantoprazole were repeated again, not acknowledged or signed by the physician. On 10/14/22 the pharmacy recommendations for a fasting lipid panel with a complete blood count with a repeat of every 12 months was not acknowledged or signed by the physician. Review of lab results for Resident #7 revealed on 08/25/22 Resident #7 refused the lab draw and the order was discontinued. On 08/28/22 a complete blood count (CBC) was completed but the renal/Depakote was not obtained at that time. Interview on 12/12/22 at 7:58 A.M. with the DON confirmed July 2022 pharmacy recommendations for Resident #7 were not signed by a nurse or physician and the order for Depakote blood draw was not completed and the order was discontinued. The DON also confirmed the recommendations by pharmacy for pantoprazole in August and again in September 2022 were not signed by a nurse or physician and the recommendations were not followed. The recommendations in October 2022 for a lipid panel with weekly CBC were also not signed or followed. 4. Review of Resident #15's medical records revealed an admitted [DATE]. Diagnosis included depression, bipolar and dementia. Review of the care plan dated 08/15/22 revealed Resident #15 had fluctuations in mood related to bipolar and depression. Interventions included observe for effectiveness of medications and report abnormalities to physician. Review of the MDS assessment dated [DATE] revealed Resident #15 had intact cognition. Review of current physician orders for December 2022 revealed Resident #15 was ordered Vanlafaxine 150 mg once daily for depression. Review of pharmacy recommendation dated 10/14/22 revealed a recommendation was made to reduce the Vanlafaxine from 150 mg to 112.5 mg due to medication could be associated with high blood pressure. Pharmacy recommendations did not contain a physician's signature or indication the recommendation was to be accepted or declined. Interview on 12/12/22 at 7:58 A.M. with the DON confirmed the pharmacy recommendations for Resident #15 had not been acknowledge by the physician, and she confirmed the current orders were still in place for Vanlafaxine at 150 mg. Interview on 12/12/22 at 11:50 A.M. with the DON revealed she had contacted the Nurse Practitioner (NP) on 12/12/22 and stated the NP had not agreed with the pharmacy recommendation to decrease the dosage. The DON confirmed the NP had not been aware of the pharmacy recommendations made on 10/14/22.

Based on interview and record review the facility failed to ensure Resident #184's baseline care plan addressed the resident's chronic pain. This affected one resident (#184) of three residents reviewed for baseline care plans. The facility census was 32. Findings include: Review of Resident #184's medical records revealed an admitted [DATE], with no listed diagnosis. Review of current physician orders for December 2022 revealed #184 was ordered Percocet (narcotic pain medication) 10-325 milligrams (mg) every eight hours for chronic pain. Review of Resident #184's baseline care plan dated 12/02/22 revealed the care plan did not address Resident #184's chronic pain. Interview on 12/04/22 at 2:20 P.M. with Resident #184's husband revealed Resident #184 was taking narcotic pain medication prior to her admission for chronic pain in her arm and shoulder and was unable to state the exact dosage, however he stated it was a lot. Observation on 12/05/22 at 8:48 A.M. revealed Resident #184 was lying in bed and was yelling out for a nurse. Upon entering Resident #184's room, Resident #184 stated she was having pain in her shoulder. Registered Nurse (RN) #441 was informed at 8:50 A.M. Review of the Medication Administration Record on 12/05/22 revealed no documentation that pain medication had been administered to Resident #184. Interview on 12/05/22 at 12:34 P.M. with RN #441 revealed she had administered pain medication to Resident #184, however she had been unable to sign off the medication in the computer system. RN #441 indicated she had signed out the medication in the narcotic book at 9:54 A.M. RN #441 stated Resident #184 had reported a pain level of eight out of 10 at that time (0= no pain and 10=worst pain imaginable). Interview on 12/12/22 at 10:10 A.M. with Director of Nursing (DON) confirmed Resident #184's baseline care plan did not address Resident #184's chronic pain. Review of facility policy titled Care Planning revised 06/24/21 revealed a baseline care plan would be developed within 48 hours and was to include interventions to provide effective person-centered care.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure appropriate care and services were provided for one resident's (Resident #2) right hip pressure ulcer. Actual Harm occurred when Resident #2's right hip pressure ulcer identified on 02/13/22 was not accurately documented in the medical record, care planned interventions were not implemented and Resident #2's pressure ulcer deteriorated to an unstageable pressure ulcer without a change in treatment. This affected one resident (Resident #2) out of three residents reviewed for pressure ulcers. Findings include: Review of Resident #2's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #2 had severe cognitive impairment and required extensive assistance of two staff members for bed mobility, transfers, and toilet use. Resident #2 was always incontinent of urine and frequently incontinent of bowel. Resident #2 did not have a pressure ulcer or injury. Review of Resident #2's Braden Scale for Predicting Pressure Sore Risk dated 09/10/21 and 12/15/21, revealed Resident #2 was at a low risk for developing pressure injury or ulcers. Review of Resident #2's progress notes on 02/13/22 revealed a change of condition note was written by Registered Nurse (RN) #200 and included Resident #2 had a skin wound or ulcer, change in skin color or condition. A treatment was ordered to apply a foam dressing and there was no change in mental status or functional status. Further review of the progress notes revealed a stage two pressure ulcer was identified and had a length of 5.0 centimeters (cm), a width of 2.0 cm, the depth was not included, and Physician Assistant (PA) #201 was notified. No further description of the pressure ulcer was documented. Review of Resident #2's physician orders on 02/13/22 revealed orders for right hip pressure area, cleanse with normal saline, pat dry, cover with foam dressing every day shift and as needed. Further review of the physician orders from 02/13/22 through 03/22/22 did not reveal orders for Resident #2's right hip pressure ulcer. Review of Resident #2's Skin and Wound Evaluation dated 02/16/22 revealed Resident #2 had an in-house acquired, stage two pressure ulcer (partial-thickness skin loss with exposed dermis) to her right trochanter (hip), the wound was present two weeks and measured a length of 6.0 cm, width of 3.9 cm and the depth was documented not applicable. Review of Resident #2's MDS assessment dated [DATE] revealed Resident #2 had severe cognitive impairment and required extensive assistance of two staff members for bed mobility, transfers, and toilet use. Resident #2 was frequently incontinent of urine and bowel and had a stage two pressure ulcer on her right hip. Review of Resident #2's Quarterly Nutritional Re-Evaluation dated 02/21/22, revealed there were no noted skin injuries and no pressure areas. The nutritional evaluation did not include the documentation of a stage two pressure ulcer to the right hip in Resident #2's medical record from 02/13/22 and 02/16/22. Review of Resident #2's medical record did not reveal a Braden Scale for Predicting Pressure Sore Risk was completed from 02/13/22 through 03/14/22. Review of Resident #2's care plan dated 03/07/22 revealed Resident #2 had and actual impairment to skin integrity related to open area right hip abrasion and reduce likelihood of pressure injury development through next review date. Skin injury of the right hip would show signs of healing by review date. Resident #2 would have no complications related to open area to right hip through the review date. Interventions included to apply pressure relieving, reducing mattress, pillows, etcetera to protect the skin while in bed; to conduct weekly head to toe skin assessments and report new, abnormal findings to physicians as needed. The care plan included Resident #2 was at risk for skin breakdown related to impaired balance, impaired mobility and cognition, dementia with behavioral disturbances, [CONDITION(S)]. Minimize risk in an effort to reduce likelihood of pressure injury development through next review date. Interventions included to turn and reposition Resident #2 every two hours and as needed. Review of Resident #2's dietary progress notes on 03/07/22 revealed documentation Resident #2 had a stage two pressure ulcer to the right hip. The resident was provided Med Pass (nutritional supplement) 120 milliliters (ml) every day to help with nutritional needs. Review of Resident #2's Wound and Skin Evaluation on 03/11/22 revealed Resident #2 had a stage two pressure ulcer of the right trochanter (hip), it was in-house acquired, and present for two weeks. The length was 3.5 cm, width of 2.8 cm, and the depth was not documented (stated not applicable). The documentation stated the wound was deteriorating. There was no documentation the physician, physician's assistant, dietician or responsible party was notified. There was no further documentation of the wound's characteristics including color, drainage, or wound bed. Review of Resident #2's Braden Scale for Predicting Pressure Sore Risk dated 03/15/22, revealed Resident #2 was at moderate risk for developing pressure injury or ulcers. Review of Resident #2's Wound and Skin Evaluation on 03/17/22 revealed Resident #2 had a stage two pressure ulcer of the right trochanter, in-house acquired, and present for two weeks. The length was 3.8 cm, width was 2.1 cm, and the depth was not documented (stated not applicable). The documentation stated the progress was stalled, and there was no documentation the physician, physician's assistant, dietician, or responsible party was notified. There was no further documentation of the wound's characteristics including color, drainage, wound bed. Review of Resident #2's progress notes from 01/28/22 through 03/22/22 did not reveal documentation Resident #2 was turned and repositioned every two hours or she refused to be turned and repositioned every two hours. Review of Resident #2's progress notes from 02/14/22 through 03/22/22 did not reveal documentation MD #202 or PA #201 were notified of Resident #2's worsening right hip pressure ulcer. There was no documentation of wound location, measurements, and characteristics. Review of Resident #2's Wound and Skin Evaluation on 03/23/22 revealed Resident #2 had a stage two pressure ulcer of the right trochanter (hip), it was in-house acquired, and present for two weeks. The length was 3.9 cm, width of 2.7 cm, and the depth was not documented (stated not applicable). The documentation stated the wound was deteriorating. There was documentation the physician, physician's assistant, and responsible party were notified. There was no documentation the dietician was notified of the deteriorating pressure ulcer. There was no documentation of the wound's characteristics including color, drainage, wound bed. Observation on 03/23/22 at 7:10 A.M. revealed Resident #2 was lying on her left side in bed. Interview on 03/23/22 at 9:55 A.M. with Director of Nursing (DON) revealed she was new to the facility since 01/03/22. The DON stated she was not certified to be a wound nurse and the facility did not use a wound physician or a wound nurse practitioner. DON stated she measured and documented information for Resident #2's pressure ulcer by using an application on her cell phone. DON stated she was still learning the system and trying to figure it out because she wanted to do it correctly. DON stated she received some instruction from Clinical Care Coordinator (CCC) #203 when she was first hired, but CCC #203 was called to a different facility and unable to return for further instruction. DON stated she took a picture of the wound with the cell phone and the application calculated the wound measurements, then she loaded the picture and wound measurements into the resident's electronic record and manually filled out the rest of the Skin and Wound evaluation for the description of the wound. DON stated she did not manually measure the pressure ulcer and compare her numbers to the cell phone measurements to ensure accuracy. DON stated she had problems with the system and some of the information did not carry over into the electronic record. When asked what interventions would be appropriate for a resident with a pressure ulcer the DON stated the resident should be lying on an air mattress. DON stated she did not know if Resident #2 was lying on an air mattress. Observation on 03/23/22 at 10:10 A.M. of Resident #2 with the DON revealed Resident #2 was not lying on a low air loss mattress. Resident #2 had a pressure redistribution foam mattress. DON confirmed Resident #2 did not have a low air loss mattress. Observation on 03/23/22 at 1:47 P.M. of Resident #2 with DON revealed Resident #2 was lying on her left side in bed and had a pressure ulcer on her right hip. The pressure ulcer was dark red around the edges of the wound, the wound bed was a light yellow white color, and the center of the wound bed had a dark gray color with a small maroon area. The pressure ulcer measured a length of 3.9 cm, width 2.5 cm, and the depth was unable to be determined because of slough tissue. A small dark red spot about the size of a dime was noted to the lower left of the pressure ulcer, and the DON stated the small dark red spot did not blanche. The DON stated the spot was not there on 03/17/22 when she evaluated the wound, and the wound bed on 03/17/22 was all white and did not have the dark gray or maroon color. Interview on 03/23/22 at 3:30 P.M. with PA #201 revealed she was not called by any nurse regarding Resident #2's pressure ulcer and she had not seen the pressure ulcer since the third or fourth week of February 2022. Interview on 03/23/22 at 3:22 P.M. with Medical Director (MD) #202 revealed he had not observed or evaluated Resident #2's pressure ulcer. MD #202 stated he relied on the nurse's to tell him if there was a problem with a pressure ulcer, and he had not received a phone call from any nurse regarding Resident #2's pressure ulcer. Interview on 03/23/22 at 3:45 P.M. with DON revealed she was notified of Resident #2's pressure ulcer to the right hip on 02/13/22, but did not do an evaluation until 02/16/22. The DON stated she did not evaluate the wound until 02/16/22 because she usually did her wound assessments on Thursday. DON stated Resident #2's right hip pressure ulcer on 03/23/22 was an unstageable pressure ulcer. When asked why the documentation for Resident #2's Skin and Wound Evaluation on 03/23/22 stated Resident #2 had a stage two pressure to the right hip and was present for two weeks, the DON verified the evaluation had incorrect information. DON stated the cell phone program for wound measurements was not working properly and would not let her update the information. DON stated the documentation in Resident #2's Wound and Skin Evaluations for 03/11/22 and 03/17/22 were also incorrect. The DON revealed on 03/11/22 the right hip pressure ulcer had yellow slough in the wound bed, and was a stage three pressure ulcer. The DON revealed on 03/17/22 the wound bed was a whitish color, had a dark red area, and was getting worse. The DON confirmed she did not notify PA #201 or MD #203 about Resident #2's deteriorating right hip pressure ulcer. When asked if the correct information about the right hip pressure ulcer was documented in the progress notes the DON stated she did not document measurements or characteristics of the right hip pressure ulcer in the progress notes from 02/16/22 through 03/23/22. After surveyor intervention documentation in the progress notes was noted on 03/23/22 regarding Resident #2's unstageable right hip pressure ulcer. Observations on 03/23/22 at 2:00 P.M., 3:00 P.M., and 4:20 P.M. of Resident #2 revealed she was lying on her left side. There was no observation of staff attempting or encouraging Resident #2 to turn and reposition. Observation on 03/23/22 at 4:20 P.M. of Resident #2 with Licensed Practical Nurse (LPN) #205 revealed Resident #2 was lying on her left side. LPN #205 stated Resident #2 liked to lay on her left hip or her right hip, and would go right back to lying on her side if she was turned. There was no observation of positioning aides in the bed or the room, and this was confirmed by LPN #205. Interview on 03/23/22 at 4:33 P.M. with Consultant Dietician (CD) #204 revealed she usually was at the facility every other week, but tested positive for COVID-19 and was out of the facility the month of February and returned on 03/07/22. CD #204 stated she remotely completed Resident #2's Quarterly Nutritional Re-Evaluation on 02/21/22 and although there were nursing progress notes on 02/13/22 regarding Resident #2's right hip pressure ulcer, CD #204 wrote Resident #2's skin was intact per notes from nursing. CD #204 stated she was first aware of Resident #2's pressure ulcer on 03/07/22, documented Resident #2 had a stage two pressure ulcer to the right hip, and Resident #2 had been on a nutritional supplement (Med Pass) for weight loss. CD #204 stated the nutritional supplement was appropriate for a stage two pressure ulcer, but additional interventions would be needed if Resident #2 had a stage three pressure ulcer. Observation on 03/24/22 at 8:20 A.M. of Resident #2's right hip pressure ulcer with PA #201 revealed Resident #2 was lying on her left side and a moderate amount of red tinged yellow drainage was observed on the dressing. The wound edges were red and sluggishly blanched around the edges. The wound bed had yellowish white tissue and the center of the wound had dark gray tissue. PA #201 stated when she saw the wound on 02/2022 it was not an open wound but now the right hip wound had deteriorated and was an unstageable pressure ulcer. When asked what information she needed about the wound to make a decision for proper treatment PA #201 stated she was not great with wounds and would ask MD #202 if she had a question. Interview on 03/24/22 at 2:01 P.M. with CCC #203 revealed there were technical issues with the application used through the cell phone for measurements of wounds. CCC #203 revealed some portions of the assessments including pictures and measurements were not crossing over into the electronic medical record, and the facility was working with the cell phone application company to fix the issues. CCC #203 stated the not applicable statement under the depth area in wound measurements had to be manually changed, the depth of a wound had to be manually measured and recorded in the Skin and Wound Evaluation. CCC #203 stated once information was loaded into the program and recorded in the resident's electronic medical record, portions of it could not be modified. Interview on 03/24/22 at 3:34 P.M. with State tested Nursing Assistant (STNA) #205 revealed she worked second and third shifts. STNA #205 stated Resident #2 would allow herself to be positioned but she didn't need to worry about turning and repositioning her because she got up to her chair for meals. STNA #205 stated she did not encourage Resident #2 to turn and reposition when she was in bed. Interview on 03/25/22 at 11:53 A.M. with RN #200 revealed she documented Resident #2 had a stage two pressure ulcer on 02/13/22, and she remembered for sure it was not open at the time. RN #200 stated Resident #2's functional status had not changed since she was admitted on [DATE], she would allow staff to position her, and she did not know why Resident #2's Braden Score for Pressure Ulcer Risk was a low risk when she was admitted and changed to a moderate risk on 03/15/22. RN #200 stated Resident #2 required total care of the staff to meet her needs. Review of the facility policy titled, Skin Management, revised 07/14/21, revealed residents with wounds, pressure injury and those at risk for skin compromise were identified, evaluated, and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation were provided to ensure optimal resident outcomes. The Braden Scale would be completed upon admission, re-admission, weekly for four weeks, quarterly, and with a significant change of status by a licensed nurse to determine the risk of pressure injury development. Appropriate preventative interventions would be implemented on residents identified at risk and the interventions were documented on the care plan. A nutritional evaluation by a Registered Dietician would evaluate all residents identified with skin impairment for nutritional status in a timely manner. Recommend labs to be drawn to evaluate protein status in all residents with existing wounds as needed. Resident's with pressure injury and lower extremity ulcers would be evaluated, measured and staged weekly in accordance with the practice guidelines until resolved. A photo could be initiated unless the resident refused. A licensed nurse would notify the attending physician with any changes as needed. A Guest/Resident at Risk meeting would be conducted at least monthly by the Interdisciplinary Team (IDT). During the meeting the IDT would evaluated resident skin changes, review treatment modalities, interventions and would make recommendations as needed. Residents reviewed for skin alterations included newly developed pressure injuries, any pressure injury that had shown no signs of healing within a two week time frame.

Based on observation, record review, interview, review of staffing and medication administration policies, job description of the Director of Nursing (DON) and facility assessment, the facility administration, having knowledge of resident care not being delivered, failed to implement its resources to ensure all residents received appropriate care to attain and maintain the highest practicable level of physical, mental, and psychosocial well-being. The facility failed to ensure a licensed nurse was assessing, monitoring, and treating residents on 10/31/21 from 7:00 A.M. to 7:00 P.M. on the COVID-19 unit that housed six residents (Resident's #8, #15, #18, #31, #37 and #43). This resulted in Immediate Jeopardy and the likelihood of actual harm when Resident #15 was not assessed due to complaints of shortness of breath, two residents (Resident's #8 and #18) did not receive scheduled insulin resulting in elevated blood glucose levels, two residents (Resident's #8 and #31) did not receive needed pain medication resulting in intolerable pain, Resident #8 did not receive ordered treatments for skin impairment, Resident #18 did not receive anti-coagulant therapy, Resident #43 did not receive anti-convulsant medication, Resident #37 did not receive her cardiac, diabetic, or arthritic pain medications as well as her topical medication to her skin impairment, and all six residents did not receive assessment of respiratory status and vital signs. On 10/31/21 at 5:08 P.M., the Administrator and RN Corporate Clinical Coordinator #600 were notified Immediate Jeopardy began on 10/31/21 when the facility failed to ensure a licensed nurse was assigned to care for residents residing on the COVID-19 unit on 10/31/21 from 7:00 A.M. to 7:00 P.M. resulting in no licensed care being provided as ordered including the administration of medication, blood glucose checks, administration of wound treatments, COVID-19 respiratory assessments, and vital signs for six residents (Resident's #8, #15, #18, #31, #37 and #43) housed on the COVID-19 unit. The Immediate Jeopardy was removed on 11/09/21 when the facility implemented the following corrective actions: · The staffing levels were reviewed by the Administrator and Regional Director of Operation (RDO) #627 on 11/09/21 at 11:05 A.M. and deemed appropriate. The facility is actively recruiting for new licensed and certified staff. On 10/31/21 the facility census was 43. · All residents (Resident's #8, #15, #18, #31, #37 and #43) on the COVID-19 unit had the potential to be affected by the staffing levels in the facility and have been reviewed and any identified issues addressed. · The Administrator will be responsible to notify RDO #627 of all call offs that cannot be covered by agency staff. (RDO) #627 had reviewed staffing requirements per regulations, appropriate mitigating staffing strategies on 11/09/21 at 11:05 A.M. with the Administrator. The staffing sheets will be reviewed by the Administrator five times weekly for one month, then weekly for one month, then monthly for three months and signed off by the Administrator/designee as appropriate to meet the needs of the residents. Any identified issues will be immediately relayed to the Director of Nursing (DON) (upon hire)/RDO #627 and RN/Corporate Clinical Coordinator #600. All staffing concerns will be submitted to and reviewed by the Quality Assurance Performance Improvement (QAPI) committee monthly for review and recommendations. The Administrator is responsible for sustained compliance. · In the event there is no scheduled licensed nurse coverage in the facility (minimum needed is one per census), the Administrator will offer incentives to employee nurses to pick up the shift(s) and attempt to secure agency contract nurses. The DON (upon hire) is responsible for clinical support inside the facility. The Administrator will notify RDO #627 of all call offs and unsuccessful attempts. In that event, a plan will be made to utilize other sister facility licensed staff and/or corporate nurse staff. Although the Immediate Jeopardy was removed on 11/09/21, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Review of the October 2021 Medication Administration Record (MAR) revealed Resident #15 did not receive any medications including cardiac, have his blood pressure and pulse monitored prior to medication administration, a respiratory screen, or vital signs including oxygen saturation level as ordered on 10/31/21 from 7:00 A.M. to 7:00 P.M. 2. Review of the October 2021 MAR revealed Resident #18 did not receive medications including an anticoagulant, and insulin, as well as blood glucose levels checked, respiratory screen or vital signs completed as ordered on 10/31/21 from 7:00 A.M. to 7:00 P.M. Review of the nursing note dated 10/31/21 at 7:23 P.M. and authored by RN #609 revealed a random blood sugar was obtained, and Resident #18's blood sugar was 397 milligrams (mg) per deciliter (dL). The nursing note revealed RN #609 notified Physician's Assistant (PA) #602 and received a new order to administer a one-time dose of insulin immediately to cover the elevated blood sugar. 3. Review of the October 2021 MAR and Treatment Administration Record (TAR) revealed Resident #8 received narcotic pain medication on 10/31/21 at 5:54 A.M. for a pain level of seven on a pain scale from zero to ten. Resident #8 did not receive any further pain medication until 10/31/21 at 7:15 P.M. when his pain level was documented as a ten on a pain scale from zero to ten. The MAR and TAR also revealed Resident #8 did not receive his insulin, blood glucose level, respiratory assessment, vital signs, and wound care treatments as ordered on 10/31/21 from 7:00 A.M. to 7:00 P.M. Review of the nursing note dated 10/31/21 at 8:29 P.M. and authored by RN #609 revealed she completed a random blood sugar check, and Resident #8's blood sugar was 374 mg dL. RN #609 notified PA #602 and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview and observation on 11/03/21 at 2:09 P.M. with Resident #8, who is cognitively intact, revealed he did not receive any of his pain medications all day one day when he was on the COVID-19 unit and was in severe pain to the point he thought he was dying from the pain. Interview on 11/04/21 at 9:57 A.M. with RN #609 revealed Resident #8 was in severe pain when she arrived on the COVID-19 unit on 10/31/21 at 7:00 P.M. as Resident #8 was crying. RN #609 assessed Resident #8's pain level as a ten on a pain scale from zero to ten as well as Resident #8 verbalized his pain level was a ten on a pain scale from zero to ten. RN #609 revealed she reviewed the MAR and was aware Resident #8 had not received narcotic pain medication since early that morning at approximately 5:00 A.M. RN #609 revealed she administered Resident #8 his pain medication and notified PA #602. 4. Review of the October 2021 MAR revealed Resident #31 had not received any medications including his pain medications, as well as a respiratory screen or vital signs completed as ordered on 10/31/21 from 7:00 A.M. to 7:00 P.M. Review of the nursing notes dated 10/31/21 at 8:07 P.M. and authored by RN #609 revealed she assessed the effectiveness of the [MEDICATION(S)] that was last provided to Resident #31 on 10/31/21 at 6:32 A.M. on 10/31/21 at 8:07 P.M. and revealed the [MEDICATION(S)] was ineffective as Resident #31's pain level was a seven on a pain scale from zero to ten. 5. Review of the October 2021 MAR for Resident #43 revealed Resident #43 did not receive any medications including anti-[CONDITION(S)] medications, respiratory screen or vital signs as ordered on 10/31/21 from 7:00 A.M. to 7:00 P.M. 6. Review of the October 2021 MAR and TAR revealed Resident #37 did not receive any ordered medications including cardiac, diabetic, arthritic pain medication, [MEDICATION(S)] treatment (anti-bacterial ointment), respiratory screen or vital signs as ordered on 10/31/21 from 7:00 A.M. to 7:00 P.M. Interview on 11/03/21 at 10:37 A.M. and 11/08/21 at 8:27 A.M. with RN Corporate Clinical Coordinator #600 verified all six residents (Resident's #8, #15, #18, #31, #37 and #43) residing on the COVID-19 unit did not receive any of their ordered medications, blood glucose checks, treatments, COVID-19 respiratory assessments, and vital signs on 10/31/21 from 7:00 A.M. to 7:00 P.M. as there was no nurse providing care to the residents on the COVID-19 unit. RN Corporate Clinical Coordinator #600 revealed the Director of Nursing (DON) walked out 10/31/21 and resigned but she was not notified that there was not a nurse on the COVID-19 unit on 10/31/21 from 7:00 A.M. to 7:00 P.M. until 11/01/21. Interview on 11/04/21 at 10:42 A.M. with RN #611 revealed she was scheduled to work at the facility on 10/31/21 from 7:00 A.M. to 11:00 A.M. but when she arrived, she was the only nurse on the non-COVID-19 unit when there were usually two nurses, and there was not a nurse on the COVID-19 unit. She revealed she was not able to get everything done on the non-COVID-19 unit so she would not have had time to go to the COVID-19 unit. RN #611 revealed she was never instructed by the Administrator or anyone else to go on the COVID-19 unit as that would have been an infection control issue going back and forth as well as she was not able to get everything done on the non-COVID-19 unit including administering medications and treatments. RN #611 revealed she refused to take the medication cart keys from the previous shift nurse that had worked on the COVID-19 unit as she made it known she was not taking responsibility for the COVID-19 unit as it was unsafe. RN #611 revealed she was unsure the previous shift nurse's name or what that nurse did with the medication cart keys. She revealed the Administrator was aware she was not going onto the COVID-19 unit. Interview with PA #602 revealed she had concerns with the health and safety of the residents especially after the facility was unable to provide nursing services on the COVID-19 unit on 10/31/21 from 7:00 A.M. to 7:00 P.M. PA #602 revealed she was concerned that during that prolonged period all the residents on the COVID-19 unit were not assessed including respiratory assessments and vital signs even though they had confirmed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #8 was in severe pain as he had not received pain medication as needed. PA #602 revealed it was unacceptable that the facility did not provide the care and services to the residents on the COVID-19 unit for that long of time as it jeopardized their safety. PA #602 revealed the DON walked out and abandoned the residents even though the DON knew the residents were not receiving the care and services required. PA #602 revealed she felt this was neglect. PA #602 revealed she brought her concerns to the Administrator on 11/01/21. Interview on 11/04/21 at 11:05 A.M. with State tested Nursing Assistant (STNA) #612 revealed on 10/31/21 from 7:00 A.M. to 7:00 P.M. he was the only staff member that worked on the COVID-19 unit, and there was not a nurse. STNA #612 revealed Resident #8 stated he had severe pain to his back and requested pain medication. STNA #612 revealed Resident #8 moaned continuously beginning mid-morning on 10/31/21. STNA #612 revealed Resident #8 continued to be in severe pain, moaning continuously and holding his back until 10/31/21 at 7:00 P.M. when RN #609 came on duty. STNA #612 revealed Resident #31 was recently admitted to the facility with a fractured left hip. STNA #612 revealed Resident #31 was in pain as he was moaning and showed signs of discomfort. STNA #612 revealed he knew Resident #31 could receive [MEDICATION(S)] for his pain but because there was no nurse on the COVID-19 unit, Resident #31 could not be assessed or receive pain medication as he should have. STNA #612 revealed he contacted the Administrator multiple times regarding no nurse and regarding Resident's #8 and #31 being in pain, and each time the Administrator stated he was working on getting a nurse. STNA #612 revealed Resident #15 continued to state that he could not breath throughout the shift. STNA #612 revealed he attempted to provide comfort but was concerned as he had no idea what his vital signs were especially his oxygen saturation level. STNA #612 revealed he notified the Administrator and RN #611 of Resident #15's complaint of difficulty breathing, and STNA #612 stated, again, they did nothing. STNA #612 revealed he felt he was stuck on the COVID-19 unit in an unsafe situation with residents in pain and having respiratory distress, and he felt helpless as he could do nothing because he was not a nurse. Interview on 11/08/21 at 4:07 P.M. with the Administrator revealed on 10/29/21 the DON resigned but gave a 30-day notice. The Administrator revealed he knew on 10/29/21 and 10/30/21 the facility still did not have a nurse for the COVID-19 unit for 10/31/21 from 7:00 A.M. to 7:00 P.M. The Administrator revealed on 10/30/21 at approximately 6:00 P.M. he assigned the DON to cover the COVID-19 unit on 10/31/21 from 7:00 A.M. to 7:00 P.M., and she had acknowledged that she was assigned. The Administrator revealed he notified RN Corporate Clinical Coordinator #600 on 10/29/21 that the DON had resigned on 10/29/21, and RN Corporate Clinical Coordinator #600 revealed she would be at the facility on 11/01/21, but he did not recall if he informed RN Corporate Clinical Coordinator #600 that they did not have nursing coverage for the Covid unit for 10/31/21 as he had assumed the DON would cover. The Administrator revealed he received a call from STNA #612 at approximately 8:00 A.M. who was working on the COVID-19 unit that there was not a nurse on the COVID-19 unit as the DON had not arrived. The Administrator revealed he attempted to contact the DON multiple times but received no return call. The Administrator attempted to contact agencies for a nurse. The Administrator revealed he notified the one nurse in the facility, RN #611, she would have to administer medication on the non-COVID-19 unit and the COVID-19 unit. The Administrator revealed he was aware the census of the facility was 43 but assumed maybe at the end of the day she would have been able to get to the COVID-19 unit. The Administrator verified he was not aware RN #611 was unable to go to the COVID-19 unit and he was not aware medications, treatments, and assessments were not completed on 10/31/21 from 7:00 A.M. to 7:00 P.M. The Administrator revealed he was not aware Resident #8 or Resident #31's pain was not being addressed as he revealed he had thought RN #611 was addressing the needs on the COVID-19 unit. The Administrator verified he did not check with RN #611 on 10/31/21 after he had assigned her to go onto the COVID-19 unit as he assumed, she was. The Administrator revealed he did not contact RN Corporate Clinical Coordinator #600 as he did not feel she would be able to assist as she lived several hours away. The Administrator also verified he did not contact RN Corporate Clinical Coordinator #600 regarding guidance regarding nursing services on 10/31/21. The Administrator also verified he did not contact the resident's primary care physicians on the COVID-19 unit or the Medical Director to notify them there was not a nurse on the unit or that there was a delay in residents receiving their medications and treatment as he revealed he felt RN #611 was going to go on the COVID-19 unit. The Administrator revealed he did contact Regional Director of Operations (RDO) #627 on 10/31/21 at approximately 11:32 A.M. regarding the situation of additional mitigating staffing steps including having RN #611 service the six residents on the COVID-19 unit. The Administrator revealed on 10/31/21 at 5:00 P.M. the DON entered the facility and resigned effective immediately and refused to assist with servicing the residents and their needs especially those residents on the COVID-19 unit. Review of the facility job description titled Director of Nursing Services, dated April 2004, revealed the primary purpose of the DON was to plan, organize, develop, and direct the overall operation of the nursing services in accordance with federal, state, and local standards, guidelines, and regulation that govern our facility and as may be directed by the Administrator to ensure quality care was always maintained. The job description revealed the DON was to coordinate the staffing needs of the nursing services necessary to meet the total nursing needs of the residents including assigning enough licensed nurses. The job description revealed the DON was to perform on call responsibilities as necessary or required and provide direct nursing care as necessary. Review of the facility policy titled Medication Administration, dated October 2019, revealed the facility failed to implement their policy as medications were to be administered in an accurate, safe, timely and sanitary manner. The policy revealed medications were to be administered within 60 minutes of the scheduled time. The policy revealed the nurse was to record the dose, route, and time of the medication on the medication or treatment record. The policy did not include ensuring the facility provided proper equipment such as PCC access, PCC badges and/or scanners were provided to the nurses in a timely manner. Review of the staffing procedure titled Mitigate Staffing Shortages, dated 07/28/20 and completed by the Administrator on 10/31/21. The procedure revealed when staffing shortages were occurring, healthcare and employers may need to implement crisis capacity strategies to continue to provide patient care. The procedure revealed the facility was to develop regional plans to identify designated healthcare facilities or alternative care sites with adequate staffing to care for patients with COVID-19. Interventions revealed under the crisis capacity strategies included implement regional plans to transfer patients with COVID-19 to designated healthcare facilities or alternative care sites with adequate staffing. The Administrator had placed a N/A (not applicable) next to this intervention. Review of the facility form titled Facility Assessment- V2, dated 01/07/21, revealed the facility average census over the past 12 months was 33. The facility assessment revealed under staffing plan, the average number of licensed nurses providing direct care in a 24- hour period was four. The facility assessment did not identify plans to service residents on the COVID-19 unit including a staffing plan. Review of facility form titled Mitigating Staffing Steps Taken For 10/31/21, completed by the Administrator revealed on 10/30/21 at 5:04 P.M. the Administrator discussed staffing for 10/31/21 with the DON, 10/30/21 at 6:01 P.M. the Administrator assigned the DON to cover the COVID-19 unit if no staff picked up, and the DON acknowledged she would cover. On 10/30/21 at 7:31 P.M. the Administrator received approval from RDO #627 to offer incentives. The form revealed on 10/31/21 at 8:12 A.M. the Administrator attempted other agencies, 10/31/21 at 8:13 A.M. the Administrator informed RN #611 that she would have to provide nursing services including medications to residents on the COVID-19 unit in the event another nurse did not pick up, 10/31/21 at 8:16 A.M. the Administrator notified the DON to see if she was aware only one nurse in the building and that she needed to come into the facility but received no response, 10/31/21 at 11:32 A.M. the Administrator notified RDO #627 of the situation and discussed additional mitigation staffing steps including having the agency nurse who was in the building service the COVID-19 residents, 10/31/21 at 12:00 P.M. the Administrator arrived at the facility, and 10/31/21 at 5:00 P.M. the DON entered the kitchen at the facility and informed the Administrator she was quitting effective immediately with no notice. This deficiency substantiates Complaint Number OH 169.

Based on interviews, observation, open and closed record review, and review of the facility policy and procedure regarding abuse and neglect prohibition the facility failed to implement an effective and appropriate process to meet the care planned needs of six residents residing on the COVID-19 positive unit (Resident's #8, #15, #18, #31, #37 and #43) on 10/31/21 from 7:00 A.M. to 7:00 P.M. when no licensed nursing staff addressed the administration of medications, pain management, skin treatments, assessments of respiratory status or vital signs that were ordered by the physician. The facility administration failed to resolve the situation, and the COVID-19 unit remained without a licensed nurse on 10/31/21 from 7:00 A.M. to 7:00 P.M. This resulted in Immediate Jeopardy that was actual harm when the facility failed to ensure Resident #15 was assessed due to complaints of shortness of breath, did not receive his cardiac medications or have his blood pressure or pulse checked prior to medication administration as ordered, Resident's #8 and #18 did not have their blood glucose levels checked and they were not given insulin as ordered resulting in elevated blood glucose levels, Resident #18 did not receive an anti-coagulant medication, Resident #43 did not receive ant-[CONDITION(S)] medication, Resident's #8 and #31 were not provided pain medications as ordered resulting in crying and moaning for an extended period due to intolerable pain, Resident #8 did not have treatments completed as ordered to bilateral ulcers to the heels, Resident #37 did not receive her cardiac, diabetic, or arthritic pain medications as well as her topical medication to her skin impairment. In addition, all residents (Resident #8, #15, #18, #31, #37, and #43) residing on the COVID-19 unit did not receive a respiratory screen or vital signs as ordered. On 11/08/21 at 5:08 P.M., the Administrator and RN Clinical Coordinator #600 were notified Immediate Jeopardy began on 10/31/21 when the facility only had one nurse, RN #611, who was assigned to the entire resident population of 43 residents in the facility and was not able to administer medications, complete respiratory assessments, blood glucose monitoring, pain assessment and pain management, anticoagulant medication and complete vital signs and treatments per physician orders for six residents (Resident's #8, #15, #18, #31, #37 and #43) residing on the COVID-19 unit on 10/31/21 from 7:00 A.M. to 7:00 P.M. This affected six residents (Resident's #8, #15, #18, #31, #37 and #43) residing on the COVID-19 unit on 10/31/21. The facility census was 43. The Immediate Jeopardy was removed on 11/09/21 when the facility implemented the following corrective actions: · Resident #8 was reviewed for medication administration and skin treatments; any identified issues were addressed. Resident #8 had skin evaluation completed Clinical Transitional Specialist/ RN #606 on 11/09/21 at 10:22 A.M. Resident #18 was reviewed for medication administration and skin treatments; any identified issues were addressed. Resident #18 is no longer at the facility. Resident # 15 was reviewed for medication administration and skin treatments; any identified issues were addressed. Resident #15 is no longer at the facility. Resident #31 was reviewed for medication administration and skin treatments; any identified issues were addressed. Resident #31 had skin evaluation completed Clinical Transitional Specialist/ RN #606 on 11/06/21 at 4:30 P.M, and Resident #37 was reviewed for medication administration and skin treatments; any identified issues were addressed. Resident #37 had skin evaluation completed Clinical Transitional Specialist/ RN #606 on 11/09/21 at 3:00 P.M. and no new areas of concern were noted. · All care plans were reviewed by RN/ Corporate Float Minimum Data Set (MDS) #624 on 11/09/21 at 4:00 P.M. and updated as deemed necessary. Resident #43 is no longer in the facility as of 11/02/21. Review on 11/10/21 at 1:00 P.M. verified Clinical Transitional Specialist/ RN #606 completed skin sweeps on all residents. The audit was reviewed with no concerns. · All residents (Resident's #8, #15, #18, #31, #37 and #43) on the Covid unit have the potential to be affected by this allegation of deficiency. There is currently one resident (Resident #44) on the COVID-19 unit that was reviewed by RN/ Corporate Clinical Coordinator #600 to ensure medications and skin treatments were administered. One medication was not administered on 11/09/21 at 9:00 A.M., and PA #602 was notified at 11/09/21 at 9:27 A.M. A new order was received on 11/09/21 at 9:27 A.M. per PA #602 to hold the medication until the evening dose. Review on 11/10/21 at 1:10 P.M. verified the corrective action plan was completed. · The abuse and neglect policy and procedure were reviewed and deemed appropriate by the Quality Assurance Performance Improvement (QAPI) meeting on 11/09/21 at 1:30 P.M. In attendance were the Administrator, RN/ Corporate Clinical Coordinator #600, Medical Director #628, and Regional Director of Operation (RDO) #627. Education was provided on 11/09/21 at 2:00 P.M. to all licensed nursing staff (one) in the facility by RN/ Corporate Clinical Coordinator #600 on abuse and neglect. The other facility licensed nurse has had a voicemail left by RN/ Regional Clinical Coordinator #625 and will be educated prior to the start of her next shift. The abuse and neglect policy and procedure education was provided to the Director of the Primary Staffing Agency #629 on 11/09/21 at 3:03 P.M. by the Administrator and will be provided to agency nurses prior to being sent to the facility. Any licensed nurses sent to the facility without education validation will receive the education by the RN/Corporate Clinical Coordinator #600 or the Director of Nursing (DON) upon hire/designee prior to start of their shift. Review of in-service training records verified licensed nurses were educated on 11/08/21 at 7:00 P.M., 11/09/21 at 7:00 A.M., 11/09/21 at 3:30 P.M., 11/09/21 at 5:10 P.M., and 11/10/21 at 7:15 A.M. at the beginning of their shift as well as the two facility nurses Licensed Practical Nurse (LPN) #630 and RN #619. Interview on 11/10/21 at 12:04 P.M. with RN #631 and RN #632 verified they received the training prior to the start of their shift, and they were knowledgeable regarding the abuse and neglect policy and procedure. · Audits will be conducted five times weekly for one month, then weekly for one month, and then monthly for three months. Audits will be conducted via observation relative to pain medication administration and insulin administration by the RN/ Corporate Clinical Coordinator #600, DON (when hired)/designee of residents on a pain management program and/or insulin to ensure that pain medication and insulin administration is completed timely. Any identified issues will be addressed immediately. Results of the audits will be forwarded monthly to the QAPI committee monthly for review and recommendations. The Administrator is responsible for sustained compliance. Although the Immediate Jeopardy was removed on 11/09/21, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings included: 1. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] and discharged to the hospital on 11/03/21. Resident #15's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 10/28/21 revealed Resident #15 was at risk for cardiac complications related to multiple cardiovascular diseases. Interventions included vital signs as ordered, and observe, document, and report any signs of cardiac distress. Review of the physician orders for 10/31/21 revealed Resident #15 was to receive [MEDICATION(S)] tablet 6 milligram (mg) by mouth one time a day for inflammation ordered for 9:00 A.M., [MEDICATION(S)] 125 microgram (mcg) tablet by mouth for heart failure ordered for 5:00 P.M. take pulse rate prior to administering, [MEDICATION(S)] tablet 50 mg one tablet by mouth ordered for 9:00 A.M. for hypertension take blood pressure and pulse prior to administering and hold if pulse rate below 60 and systolic blood pressure less than 100, and [MEDICATION(S)] (anticonvulsant) 300 mg one capsule by mouth ordered for 9:00 A.M., 1:00 P.M. and 5:00 P.M. Also, Resident #15 had orders for a respiratory screener to be completed on dayshift, vital signs including blood pressure, pulse, temperature, and oxygen saturation level to be completed on dayshift. Review of the October 2021 Medication Administration Record (MAR) revealed Resident #15 did not receive any of his ordered medications on 10/31/21 from 7:00 A.M. to 7:00 P.M as well as he did not have an assessment of his respiratory status and vital signs completed on dayshift as ordered. Interview on 11/03/21 at 10:37 A.M. and 11/08/21 at 8:27 A.M. with RN Corporate Clinical Coordinator #600 verified Resident #15 did not receive any of his ordered medications on 10/31/21 from 7:00 A.M. to 7:00 P.M. as there was not a nurse on the COVID-19 unit. RN Corporate Clinical Coordinator #600 also verified Resident #15 did not have an assessment of his respiratory status or vital signs completed as ordered on dayshift on 10/31/21. Interview on 11/04/21 at 11:05 A.M. with STNA #612 revealed on 10/31/21 from 7:00 A.M. to 7:00 P.M. he was the only staff that worked on the COVID-19 unit, and there was not a nurse to provide care. STNA #612 revealed Resident #15 continued to state that he could not breath. STNA #612 revealed he attempted to provide comfort but was concerned as he had no idea how Resident #15's vital signs were, especially his oxygen saturation level. STNA #612 revealed he notified the Administrator and RN #611 of Resident #15's complaints of difficulty breathing, and STNA #612 stated, again, they did nothing. STNA #612 revealed he felt he was stuck on the COVID-19 unit in an unsafe situation with residents in pain and having respiratory issues, and he felt helpless as he could do nothing since he was not a nurse. 2. Review of the medical record for Resident #18 revealed an admitted [DATE] and discharge date of [DATE] to another facility. Resident #18's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 10/28/21 revealed Resident #18 did not have a care plan regarding management of his diabetes. Review of the physician orders for 10/31/21 revealed Resident #18 was to receive [MEDICATION(S)] 6 mg by mouth ordered for 9:00 A.M. for inflammation, [MEDICATION(S)] 5 mg one tablet by mouth for hypertension ordered for 9:00 A.M., [MEDICATION(S)] solution (anticoagulant) 40 mg per 0.4 milliliter (ml) inject subcutaneously ordered for 10:00 A.M., [MEDICATION(S)] 5 mg tablet by mouth ordered for 9:00 A.M. for diabetes, [MEDICATION(S)] 1000 mg one tablet by mouth ordered for 9:00 A.M. and 5:00 P.M. for diabetes, [MEDICATION(S)] capsule 100 mg give one capsule by mouth for cough at 9:00 A.M., 1:00 P.M. and 5:00 P.M., obtain glucose level at 8:00 A.M., 12:00 P.M. and 5:00 P.M. and inject [MEDICATION(S)]-solution 100 units per ml subcutaneously per sliding scale. Resident #18 also had orders for a respiratory screen to assess his respiratory status ordered for lunch time due to confirmed COVID-19 and vital signs including blood pressure, pulse, respirations, temperature, and oxygen saturation level ordered for lunch time. Review of the October 2021 MAR revealed Resident #18 did not receive medications, glucose levels, insulin, respiratory screen, vital signs, and oxygen saturation checks as ordered on 10/31/21 from 7:00 A.M. to 7:00 P.M. Review of the nursing note dated 10/31/21 at 7:23 P.M. and authored by RN #609 revealed a random blood sugar was obtained, and Resident #18's blood sugar was elevated at 397 milligrams (mg) per deciliter (dL). The nursing note revealed RN #609 notified PA #602 and received a new order to administer one dose of eight units of regular insulin immediately to cover the elevated blood sugar. Interview on 11/03/21 at 10:37 A.M. and 11/08/21 at 8:27 A.M. with RN Corporate Clinical Coordinator #600 verified Resident #18 did not receive any of his medications, glucose levels, insulin, anti-coagulant medication, respiratory screen, vital signs, and oxygen saturation checks as ordered on 10/31/21 from 7:00 A.M. to 7:00 P.M. as there was not a nurse on the COVID-19 unit. RN Corporate Clinical Coordinator #600 verified Resident #18's blood sugar was taken on 10/31/21 at 7:23 P.M. and was elevated at 397 mg dL requiring a one-time dose of regular insulin that was ordered by PA #602 to cover the elevated blood sugar. Interview on 11/03/21 at 11:45 A.M. with PA #602 revealed on 10/31/21 at approximately 7:30 P.M. she was notified by RN #609 that there had not been a nurse on the COVID-19 unit on 10/31/21 from 7:00 A.M. to 7:00 P.M. The facility only had an STNA on the unit, and Resident #18 did not receive any medications during this time including his insulin. PA #602 revealed RN #609 checked Resident #18's blood sugar and it was 397 mg dL, and she ordered a one-time dose of eight units of regular insulin due to the elevated blood sugar. 3. Review of the medical record revealed Resident #8 had an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission physician orders for October 2021 revealed Resident #8 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M. for fluid retention and to have his blood pressure checked; hold the [MEDICATION(S)] if the systolic blood pressure was below 110, [MEDICATION(S)] 100 mg give one capsule my mouth ordered for 5:00 P.M. for nerve pain, [MEDICATION(S)] extended release 600 mg by mouth for cough ordered for 9:00 A.M., NPH insulin suspension 100 units per ml give 10 ml subcutaneously one time a day before breakfast for diabetes ordered for 7:30 A.M., NPH insulin suspension 100 units per ml give 11 units subcutaneously in the evening before dinner for diabetes ordered for 5:00 P.M., [MEDICATION(S)] 25 mg tablet by mouth two times a day for hypertension; check blood pressure and hold if the systolic blood pressure was less than 110 or if heart rate was less than 50 was ordered for 9:00 A.M., check blood glucose level and administer [MEDICATION(S)] insulin 100 units per ml subcutaneously per sliding scale before meals for diabetes ordered for 11:00 A.M. and 4:00 P.M., Oxycodone- Acetaminophen 10-325 mg tablet by mouth every four hours as needed for pain, Acetaminophen 325 mg tablet administer two tablets every four hours as needed for mild pain. Resident #8 also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #8 had treatment orders that included cleanse the right heel with normal saline, apply [MEDICATION(S)](antiseptic) and calcium alginate (dressing for heavily draining wounds) and cover with foam dressing ordered to be completed at 5:00 P.M., and cleanse the left heel with normal saline, pat dry, apply [MEDICATION(S)], cover with abdominal (ABD) pad, and wrap with Kerlix gauze ordered to be completed at 5:00 P.M. Review of the October 2021 MAR revealed Resident #8 received Oxycodone- Acetaminophen 10-325 mg tablet by mouth on 10/31/21 at 5:54 A.M. for a pain level of seven on a pain scale of zero to ten. Resident #8 did not receive any further Oxycodone- Acetaminophen until 10/31/21 at 7:15 P.M. when his pain level was documented as a ten on a pain scale of zero to ten. The MAR revealed Resident #8 did not receive any of the ordered medications on 10/31/21 from 7:00 A.M. to 7:00 P.M., and did not have his blood glucose level checked, respiratory assessment, vital signs, oxygen saturation, and treatments to his bilateral heels completed as ordered. Review of the admission assessment for Resident #8 labeled Nursing Comprehensive Evaluation V1-V13, dated 10/28/21, and completed by RN #618 revealed Resident #8 required two-staff assistance with transfers and bed mobility. The evaluation revealed Resident #8 had skin issues described as right heel sores and left heel sores, but there was no description of the affected areas or any measurements. The assessment also revealed Resident #8 was currently having pain and had pain in the last five days. Resident #8 revealed his pain was in his lower back and bilateral heels. Resident #8 revealed his present pain was an eight on a pain scale of zero to ten. Resident #8 indicated his pain could get as bad as a 10 on a pain scale of zero to ten. Review of the care plan dated 10/28/21 revealed Resident #8 had actual impairment to his skin integrity. Interventions included observe location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 10/28/21 revealed Resident #8 was at risk for pain. Interventions included anticipate resident's need for pain relief as needed and respond immediately to any complaint of pain, notify the physician if interventions were unsuccessful or if current complaint was a significant change from resident's experience of pain. Resident #8 did not have a care plan related to management of diabetes. Review of the admission Brief Interview for Mental Status (BIMS) dated 10/29/21 revealed Resident #8 was cognitively intact with a BIMS score of a 15. Review of the facility form labeled Braden Scale for Predicting Pressure Sore Risk, dated 10/29/21, for Resident #8 revealed it was in progress and not completed. Review of the nursing note dated 10/31/21 at 8:29 P.M. and authored by RN #609 revealed she completed a random blood sugar check, and Resident #8's blood sugar was 374 mg dL. RN #609 notified PA #602 and received an order to give NPH insulin 11 units now. Interview on 11/03/21 at 10:37 A.M. and 11/08/21 at 8:27 A.M. with RN Corporate Clinical Coordinator #600 verified there was only one STNA on the COVID-19 unit, and there was not a nurse on 10/31/21 from 7:00 A.M. to 7:00 P.M. RN Corporate Clinical Coordinator #600 verified Resident #8 did not receive any medications, blood sugar checks, respiratory screen, vital signs, glucose levels, oxygen saturation level, or treatments to the bilateral heels as ordered on 10/31/21 from 7:00 A.M. to 7:00 P.M. RN Corporate Clinical Coordinator #600 revealed the DON walked out, and the Administrator was aware and tried to get a nurse but was unable. Interview on 11/03/21 at 11:45 A.M. with PA #602 revealed on 10/31/21 at approximately 7:30 P.M. she was notified by RN #609 that there had not been a nurse on the COVID-19 unit on 10/31/21 from 7:00 A.M. to 7:00 P.M. The facility only had an STNA on the unit, and Resident #8 did not receive any medications during this time. PA #602 revealed she was aware Resident #8 did not receive any pain medications all day and was in severe pain when RN #609 had arrived on duty. PA #602 revealed Resident #8 had chronic back pain and received medications as needed to control his pain. PA #602 revealed RN #609 administered Resident #8's pain medication when she arrived on the unit at approximately 7:00 P.M. PA #602 also revealed she was aware Resident #8 had not had his blood glucose level checked or any ordered insulin on 10/31/21 from 7:00 A.M. to 7:00 P.M. PA #602 revealed RN #609 checked Resident #8's blood glucose level and it was 374 mg dL, and she ordered NPH insulin 11 units to be given right away and recheck his blood glucose level. Interview and observation on 11/03/21 at 2:09 P.M. with Resident #8, who is cognitively intact, revealed he did not receive any of his pain medications all day one day when he was on the COVID-19 unit and was in severe pain to the point he thought he was dying from the pain. Resident #8 also revealed he had a dressing to his right calve area that was not dated. Resident #8 did not appear to have a dressing to his right heel as ordered and Resident #8 had a sock on his left foot preventing observation of the left heel dressing. Resident #8 revealed the nurses do not change his dressing daily. Resident #8 revealed he thought the nurse changed the dressing two days ago. Observation of Resident #8's dressing change on 11/03/21 at 2:35 P.M. with Clinical Corporate Transitional Specialist/ RN #606 revealed Resident #8 had a dressing to his right calve area that was undated and a dressing to his left heel that was undated. Resident #8 did not have a dressing to his right heel as ordered. Observation of Resident #8's wound care and interview on 11/03/21 at 4:10 P.M. completed by Clinical Corporate Transitional Specialist/ RN #606 revealed Resident #8 had an open area to his right outer leg that measured 2.0 centimeter (cm) in length by 4.0 cm in width by 0.1 cm in depth. Clinical Corporate Transitional Specialist/ RN #606 verified Resident #8 did not have an open area or wound to the right heel. Observation revealed Resident #8 had an undated dressing to the left foot but not the left heel. Clinical Corporate Transitional Specialist/ RN #606 removed the dressing to the upper left foot revealing gangrene to the left fourth and fifth toes and an open area to the great toe area that measured 4.0 cm in length by 2.0 cm in width by and 0.1 cm in depth. The area had yellow drainage in the center. Interview on 11/03/21 at 4:15 P.M. with Clinical Corporate Transitional Specialist/ RN #606 verified the admission Nursing Comprehensive Evaluation dated 10/28/21 contained inaccurate documentation as Resident #8 did not have wounds to the bilateral heels, instead Resident #8 had one wound to the right calve area and a wound to the left great toe area as well as gangrene to the fourth and fifth toes which were not identified on the admission assessment. Clinical Corporate Transitional Specialist/ RN #606 verified the admission assessment should have included measurements and a description of the areas and not documented as sores. Clinical Corporate Transitional Specialist/ RN #606 verified the treatment orders were inaccurate as they both read for the heels instead of the proper location of the wounds. The RN also verified there was no documented evidence the treatments were completed on 10/31/21 and the dressings were not dated. Clinical Corporate Transitional Specialist/ RN #606 verified Resident #8 did not have a Braden Scale Risk Assessment completed on admission. She stated she would contact Resident #8's Primary Care Physician #900 for new treatment orders. Review of the nursing note dated 11/03/21 at 7:40 P.M. and authored by Clinical Corporate Transitional Specialist/ RN #606 revealed Resident #8 had wounds to the left foot and two black toes, and Resident #8's great toe area status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound bed had 80 percent granulation tissue and had no signs of infection. Resident #8's outer calf was noted to have an abrasion that was superficial. The area measured 2.0 cm in length by 4.0 cm in width by 0.1 cm in depth. The orders were clarified. Review of the Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #8 revealed it was still in progress. Interview on 11/04/21 at 11:05 A.M. with STNA #612 revealed on 10/31/21 from 7:00 A.M. to 7:00 P.M. he was the only staff that worked on the COVID-19 unit, and there was not a nurse. STNA #612 revealed Resident #8 stated he had severe pain to his back and requested pain medication. STNA #612 revealed Resident #8 moaned out continuously which began mid-morning on 10/31/21. STNA #612 revealed he contacted the Administrator multiple times regarding no nurse and Resident #8's pain, and each time the Administrator stated he was working on getting a nurse. STNA #612 revealed Resident #8 continued to be in severe pain, moaning out continuously and holding his back until 10/31/21 at 7:00 P.M. when RN #609 came on duty. STNA #612 revealed he felt terrible as there was nothing, he could do except try to reposition Resident #8 and make him more comfortable. Interview on 11/04/21 at 9:57 A.M. with RN #609 revealed Resident #8 was in severe pain when she arrived on the Covid unit on 10/31/21 at 7:00 P.M. Resident #8 was crying and had a pain level assessed as a 10 on a pain scale of zero to ten. RN #609 revealed she reviewed the MAR and was aware Resident #8 had not received Oxycodone-Acetaminophen since early that morning at approximately 5:00 A.M. RN #609 revealed she medicated Resident #8 with Oxycodone- Acetaminophen 10-325 mg tablet per the as needed order and notified PA #602. 4. Review of the medical record for Resident #31 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders for 10/31/21 revealed Resident #31 had the following orders: [MEDICATION(S)] 200 mg by mouth ordered for 9:00 A.M. for [CONDITION(S)], [MEDICATION(S)] 5 mg tablet by mouth for prostate [CONDITION(S)] ordered for 9:00 A.M., [MEDICATION(S)] aerosol 100-25 mcg to administer one inhalation was ordered for 9:00 A.M. for [CONDITION(S)], [MEDICATION(S)] patch 4 percent apply to affected area due to left femur fracture which was to be applied at 9:00 A.M., [MEDICATION(S)] 25 mg by mouth for depression ordered for 9:00 A.M., [MEDICATION(S)] hand held inhaler 18 mcg one capsule inhale orally for [CONDITION(S)] ordered for 9:00 A.M., [MEDICATION(S)]-[MEDICATION(S)] aerosol 160-4.5 mcg two puffs for [CONDITION(S)] ordered for 9:00 A.M Resident #31 also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #31 also had physician orders to have a respiratory screen completed at lunch every day, vital signs including blood pressure, temperature, pulse, respirations, and oxygen saturation rate to be completed at 2:00 P.M. every day. Review of the admission assessment labeled Nursing Comprehensive Evaluation, dated 10/30/21, completed by RN #621 revealed Resident #31 was not having pain and had not had pain in the last five days. Review of the October 2021 MAR revealed Resident #31 had not received any medications ordered on 10/31/21 from 7:00 A.M. to 7:00 P.M. Resident #31 had a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR revealed Resident #31 received [MEDICATION(S)] on 10/30/21 at 8:37 P.M. for a pain level of seven on a pain scale from zero to ten that was effective. The MAR revealed Resident #31 was administered [MEDICATION(S)] on 10/31/21 at 6:32 A.M. and it was documented Resident #31's pain level was an eight on a pain scale from zero to ten, and the [MEDICATION(S)] was ineffective for Resident #31's pain. Resident #31 also had physician orders to have a respiratory screen completed at lunch every day, vital signs including blood pressure, temperature, pulse, respirations, and oxygen saturation rate completed at 2:00 P.M. every day that were not completed on 10/31/21 from 7:00 A.M. to 7:00 P.M. Review of the nursing notes dated 10/31/21 at 8:07 P.M. and authored by RN #609 revealed she assessed the effectiveness of the [MEDICATION(S)] that was provided to Resident #31 on 10/31/21 at 6:32 A.M. and revealed the [MEDICATION(S)] was ineffective as Resident #31's pain level was a seven on a pain scale from zero to ten. There was no documented evidence in the nursing notes of any intervention provided for Resident #31's pain. There was no documented evidence he received additional pain management medication or that PA #602 was notified regarding his pain level being a seven. Review of the physician orders dated 11/02/21 revealed Resident #31 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 11/04/21 at 11:05 A.M. with STNA #612 revealed on 10/31/21 from 7:00 A.M. to 7:00 P.M. he was the only staff that worked on the Covid-19 unit, and there was not a nurse. STNA #612 revealed Resident #31 was recently admitted to the facility with a fractured hip. STNA #612 revealed Resident #31 was in pain as he was moaning and showed signs of discomfort. STNA #612 revealed he knew Resident #31 could receive [MEDICATION(S)] for pain but because there was no nurse on the COVID-19 unit, Resident #31 could not be assessed or receive pain medication as he should have. STNA #612 revealed he contacted the Administrator multiple times regarding no nurse and Resident #31 being in pain, and each time the Administrator stated he was working on getting a nurse. STNA #612 revealed he was frustrated as he knew Resident #31 was in pain, and he was a STNA unable to give medications and all he could do was try to make Resident #31 comfortable by repositioning him in bed for comfort. Review of the Admission MDS 3.0 assessment dated [DATE] revealed it was still in progress. Observation and interview on 11/09/21 at 11:24 A.M. revealed Resident #31 was up in the recliner visiting with Resident #31's daughter and displayed no signs of pain or discomfort. Resident #31 revealed his pain level was about a four on a pain scale from zero to ten. Resident #31 could not provide any information regarding concerns of pain while on the COVID-19 unit. Resident #31's daughter revealed she was not able to visit when he was on the COVID-19 unit and was not able to communicate with him on the phone, so she had no information regarding his pain management when Resident #31 resided on the COVID-19 unit. Interview on 11/03/21 at 10:37 A.M. and 11/08/21 at 8:27 A.M. with RN Corporate Clinical Coordinator #600 verified Resident #43 did not receive any of his ordered medications, respiratory assessment, or vital signs on 10/31/21 from 7:00 A.M. to 7:00 P.M. as there was not a nurse on the COVID-19 unit. 5. Review of the medical record for Resident #43 revealed an admitted [DATE] and a discharge date of [DATE]. Resident #43's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 10/28/21 revealed Resident #43 was at risk for [CONDITION(S)] disorder. Interventions included labs as ordered and [CONDITION(S)] precautions. Review of the care plan dated 10/28/21 revealed Resident #43 was at risk for cardiac complications related to cardiovascular disease. Interventions included labs as ordered and vital signs as ordered. Review of the physician orders for 10/31/21 revealed Resident #43 had orders including: [MEDICATION(S)] (diuretic) 50 mg tablet by mouth ordered for 9:00 A.M., [MEDICATION(S)] 20 mg by mouth for depression ordered for 9:00 A.M., [MEDICATION(S)] 3.125 mg tablet for hypertension ordered for 8:00 A.M., [MEDICATION(S)] 500 mg tablet for [CONDITION(S)] ordered for 9:00 A.M., [MEDICATION(S)] 300 mg capsule by mouth for [CONDITION(S)] ordered for 9:00 A.M., 1:00 P.M. and 5:00 P.M. Resident #43 also had physician orders to have a respiratory screen completed at lunch every day, and vital signs including blood pressure, temperature, pulse, respirations, and oxygen saturation rate completed at lunch time every day that were not completed on 10/31/21 from 7:00 A.M. to 7:00 P.M. Review of the October 2021 MAR rev

Based on record review, interviews, review of staffing policies, job description of the Director of Nursing (DON) and facility assessment, the facility failed to ensure a licensed nurse was assigned to care for six residents (Resident's #8, #15, #18, #31, #37 and #43) residing on the COVID-19 unit on 10/31/21 from 7:00 A.M. to 7:00 P.M. resulting in no licensed care being completed including the administration of medication, administration of skin treatments, respiratory assessments, blood glucose checks, and vital signs as ordered. The facility had one agency nurse, Registered Nurse (RN) #611, on duty for the resident population of 43 residents and she did not include the care of the residents on the COVID-19 unit. This resulted in Immediate Jeopardy on 10/31/21 when the COVID-19 unit did not have a licensed nurse assigned to care for the residents on 10/31/21 from 7:00 A.M. to 7:00 P.M. The lack of adequate staffing resulted in actual harm or the potential for serious harm when Residents #8 and #31 experienced intolerable pain when they were not assessed or provided pain medications as ordered, Residents #8 and #18 experienced elevated blood sugars when they did not have their blood glucose levels checked or their ordered insulin administered, Resident #8 did not receive wound care treatments, and Resident's #8, #15, #18, #31, #37 and #43 did not have medication administration, respiratory assessments and vital signs completed as ordered. This affected all six residents residing on the COVID-19 unit. The facility census was 43. On 10/31/21 at 5:08 P.M., the Administrator and RN Corporate Clinical Coordinator #600 were notified Immediate Jeopardy began on 10/31/21 when the facility failed to ensure a licensed nurse was assigned to care for six residents (Resident's #8, #15, #18, #31, #37 and #43) residing on the COVID-19 unit from 7:00 A.M. to 7:00 P.M. resulting in no licensed care being completed as ordered including the administration of medication, blood glucose checks, administration of skin treatments, COVID-19 respiratory assessments, and vital signs. The Immediate Jeopardy was removed on 11/09/21 when the facility implemented the following corrective actions: · The staffing levels were reviewed by the Administrator and Regional Director of Operation (RDO) #627 on 11/09/21 at 10:55 A.M. and deemed appropriate. The facility is actively recruiting for new licensed and certified staff. · All residents (Resident's #8, #15, #18, #31, #37 and #43) on the COVID-19 unit had the potential to be affected by the staffing levels in the facility and have been reviewed and any identified issues addressed. · RDO #627 reviewed staffing requirements per regulations, appropriate mitigating staffing strategies on 11/09/21 at 10:55 A.M. with the Administrator. The staffing sheets will be reviewed by the Administrator five times weekly for one month, then weekly for one month, then monthly for three months and signed off by the Administrator/designee as appropriate to meet the needs of the residents. Any identified issues will be immediately relayed to the Director of Nursing (DON) (upon hire)/RDO #627 and RN/ Corporate Clinical Coordinator #600. All staffing concerns will be submitted to and reviewed by the Quality Assurance Performance Improvement (QAPI) committee monthly for review and recommendations. The Administrator is responsible for sustained compliance. · In the event there is no scheduled licensed nurse coverage in the facility (minimum needed is one per census), the Administrator will offer incentives to employee nurses to pick up the shift(s) and attempt to secure agency contract nurses. The DON (upon hire) is responsible for clinical support inside the facility. Until a DON is hired, RN Corporate Clinical Coordinator #600 (Acting DON) is responsible for clinical support inside the facility. The Administrator will notify RDO #627 of all call offs and unsuccessful attempts. In that event, a plan will be made to utilize other sister facility licensed staff and/or corporate nurse staff. Although the Immediate Jeopardy was removed on 11/09/21, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M., [MEDICATION(S)] 125 microgram (mcg) tablet by mouth for heart failure ordered for 5:00 P.M. and to take a pulse rate prior to administering, [MEDICATION(S)] tablet 50 mg one tablet by mouth ordered for 9:00 A.M. for hypertension and to take a blood pressure and pulse prior to administering the medication and hold if the pulse rate was below 60 and systolic blood pressure less than 100, and [MEDICATION(S)] (anticonvulsant) 300 mg one capsule by mouth ordered for 9:00 A.M., 1:00 P.M. and 5:00 P.M. Also, Resident #15 had orders for a respiratory screener to assess his respiratory status and vital signs including blood pressure, pulse, temperature, and oxygen saturation level to be completed on day shift. Review of the October 2021 Medication Administration Record (MAR) revealed Resident #15 did not receive any of his ordered medications on 10/31/21 from 7:00 A.M. to 7:00 P.M as well as Resident #15 did not have an assessment of his respiratory status due to confirmed COVID-19 and vital signs completed on day shift as ordered. 2. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. for inflammation, [MEDICATION(S)] 5 mg one tablet by mouth for hypertension ordered for 9:00 A.M., [MEDICATION(S)] solution (anticoagulant) 40 mg per 0.4 milliliter (ml) inject subcutaneously ordered for 10:00 A.M., [MEDICATION(S)] 5 mg tablet by mouth ordered for 9:00 A.M. for diabetes, [MEDICATION(S)] 1000 mg one tablet by mouth ordered for 9:00 A.M. and 5:00 P.M. for diabetes, [MEDICATION(S)] capsule 100 mg give one capsule by mouth for cough at 9:00 A.M., 1:00 P.M., and 5:00 P.M., obtain a glucose level at 8:00 A.M., 12:00 P.M. and 5:00 P.M. and inject [MEDICATION(S)]-solution 100 units per ml subcutaneously per sliding scale. Resident #18 also had orders for a respiratory screener to assess respiratory status due to confirmed COVID-19, and vital signs including blood pressure, pulse, respirations, temperature, and oxygen saturation level ordered for lunch time. Review of the October 2021 MAR revealed Resident #18 did not receive any of his medications, respiratory screen, blood glucose checks, or vital signs as ordered on 10/31/21 from 7:00 A.M. to 7:00 P.M. Review of the nursing note dated 10/31/21 at 7:23 P.M. and authored by RN #609 revealed a random blood sugar was obtained, and Resident #18's blood sugar was 397 mg dL. The nursing noted revealed RN #609 notified Physician's Assistant (PA) #602 and received a new order to administer one dose of 8 units of regular insulin immediately to cover the elevated blood sugar. 3. Review of the admission physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. for fluid retention and to have his blood pressure checked and hold the [MEDICATION(S)] if systolic blood pressure was below 110, [MEDICATION(S)] 100 mg give one capsule my mouth ordered for 5:00 P.M. for nerve pain, [MEDICATION(S)] 600 mg by mouth for cough ordered for 9:00 A.M., NPH insulin suspension 100 units per ml give 10 ml subcutaneously one time a day before breakfast for diabetes ordered for 7:30 A.M., NPH insulin suspension 100 units per ml give 11 units subcutaneously in the evening before dinner for diabetes ordered for 5:00 P.M., [MEDICATION(S)] 25 mg tablet by mouth two times a day for hypertension and check blood pressure and hold the medication if the systolic blood pressure was less than 110 or if the heart rate was less than 50 ordered for 9:00 A.M., check blood glucose level and administer [MEDICATION(S)] insulin 100 units per ml by injecting subcutaneously per sliding scale before meals for diabetes ordered for 11:00 A.M. and 4:00 P.M., Oxycodone-Acetaminophen 10-325 mg tablet by mouth every four hours as needed for pain, Acetaminophen 325 mg tablet administer two tablets every four hours as needed for mild pain. Resident #8 also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #8 had treatments orders including: cleanse the right heel with normal saline, apply [MEDICATION(S)] (antiseptic) and calcium alginate (dressing for heavily draining wounds) and cover with foam dressing ordered to be completed at 5:00 P.M., and cleanse the right heel with normal saline, pat dry, apply [MEDICATION(S)], cover with abdominal (ABD) pad, and wrap with Kerlix gauze ordered to be completed at 5:00 P.M. Review of the October 2021 MAR and Treatment Administration Record (TAR) revealed Resident #8 received Oxycodone-Acetaminophen 10-325 mg tablet by mouth on 10/31/21 at 5:54 A.M. as Resident #8's pain level was a seven on a pain scale from zero to ten. Resident #8 did not receive any further Oxycodone-Acetaminophen until 10/31/21 at 7:15 P.M. when his pain level was documented as a ten on a pain scale from zero to ten. The MAR and TAR revealed Resident #8 did not receive any of his medications, blood glucose level checks, respiratory assessment, vital signs, and treatments completed as ordered on 10/31/21 from 7:00 A.M. to 7:00 P.M. Review of the nursing note dated 10/31/21 at 8:29 P.M. and authored by RN #609 revealed she completed a random blood sugar check, and Resident #8's blood sugar was 374 mg dL. RN #609 notified PA #602 and received an order to give NPH insulin 11 units now. Interview on 11/03/21 at 2:09 P.M. with Resident #8, who is cognitively intact with a Brief interview for Mental Status (BIMS) score of 15, revealed he did not receive any of his pain medications all day one day when he was on the COVID-19 unit and was in severe pain to the point he thought he was dying from the pain. Resident #8 revealed the nurses do not change his dressings daily. Interview on 11/4/21 at 9:57 A.M. with RN #609 revealed Resident #8 was in severe pain when she arrived on the COVID-19 unit on 10/31/21 at 7:00 P.M. Resident #8 was crying, and RN #609 assessed his pain level as a 10 as well as Resident #8 verbalized his pain level was a 10 on a pain scale from zero to ten. RN #609 revealed she reviewed the MAR and was aware Resident #8 had not received any Oxycodone-Acetaminophen since early that morning at approximately 5:00 A.M. RN #609 revealed she medicated Resident #8 with Oxycodone-Acetaminophen 10-325 mg tablet per the as needed order and notified PA #602. 4. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. for [CONDITION(S)], [MEDICATION(S)] 5 mg tablet by mouth for prostate [CONDITION(S)] ordered for 9:00 A.M., [MEDICATION(S)] aerosol 100- 25 micrograms (mcg) administer one inhalation ordered for 9:00 A.M. for [CONDITION(S)], [MEDICATION(S)] patch 4 percent apply to affected area due to left femur fracture to be applied at 9:00 A.M., [MEDICATION(S)] 25 mg by mouth for depression ordered for 9:00 A.M., [MEDICATION(S)] hand held inhaler 18 mcg one capsule inhale orally for [CONDITION(S)] ordered for 9:00 A.M. [MEDICATION(S)]-[MEDICATION(S)] aerosol 160-4.5 mcg two puffs for [CONDITION(S)] ordered for 9:00 A.M Resident #31 also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, Resident #31 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. every day. Review of the October 2021 MAR revealed Resident #31 had not received any of his medications, respiratory screen, or vital signs completed as ordered on 10/31/21 from 7:00 A.M. to 7:00 P.M. Resident #31 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing notes dated 10/31/21 at 8:07 P.M. and authored by RN #609 revealed she assessed the effectiveness of the [MEDICATION(S)] that was provided to Resident #31 on 10/31/21 at 6:32 A.M. at 10/31/21 8:07 P.M. and revealed the [MEDICATION(S)] was ineffective as Resident #31's pain level was a seven on a pain scale from zero to ten. 5. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M., [MEDICATION(S)] 20 mg by mouth for depression ordered for 9:00 A.M., [MEDICATION(S)] 3.125 mg tablet for hypertension ordered for 8:00 A.M., [MEDICATION(S)] 500 mg tablet for [CONDITION(S)] ordered for 9:00 A.M., [MEDICATION(S)] 300 mg capsule by mouth for [CONDITION(S)] ordered for 9:00 A.M., 1:00 P.M. and 5:00 P.M. Resident #43 also had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the October 2021 MAR revealed Resident #43 did not receive any of his medications, respiratory screen, and vital signs as ordered on 10/31/21 from 7:00 A.M. to 7:00 P.M. 6. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M., [MEDICATION(S)] 200 mg by mouth for COVID-19 ordered for 9:00 A.M., [MEDICATION(S)] patch 4 percent topically to affected area for arthritis ordered to be applied at 9:00 A.M., [MEDICATION(S)] 2.5 mg by mouth for hypertension ordered for 9:00 A.M., [MEDICATION(S)] (steroid) 2.5 mg tablet by mouth to be given with [MEDICATION(S)] 3 mg tablet by mouth ordered for 9:00 A.M., and [MEDICATION(S)] 2.5 mg by mouth for diabetes ordered for 9:00 A.M. and 5:00 P.M. Resident #37 also had treatment orders that included [MEDICATION(S)] ointment two percent to apply to healing wounds (there was no location of wound noted on the order) ordered at 2:00 P.M., respiratory screen for Covid-19 was to be completed at lunch time, and vital signs including blood pressure, pulse, temperature, and oxygen saturation rate due to COVID-19 were to be completed at 1:00 P.M. Review of the October 2021 MAR and TAR for Resident #37 revealed Resident #37 did not receive any of the ordered medications, [MEDICATION(S)] treatment, respiratory screen, or vital signs completed as ordered on 10/31/21 from 7:00 A.M. to 7:00 P.M. Interview on 11/03/21 at 10:37 A.M. and 11/08/21 at 8:27 A.M. with RN Corporate Clinical Coordinator #600 verified all six residents (Resident's #8, #15, #18, #31, #37 and #43) residing on the COVID-19 unit did not receive any of their ordered medications, treatments, COVID-19 respiratory assessments, blood glucose checks, and vital signs on 10/31/21 from 7:00 A.M. to 7:00 P.M. as there was not a nurse on the COVID-19 unit. RN Corporate Clinical Coordinator #600 revealed she was not aware there was not a nurse on the COVID-19 unit and that no medication or treatments were completed on 10/31/21 from 7:00 A.M. to 7:00 P.M. until 11/01/21. RN Corporate Clinical Coordinator #600 revealed the DON walked out on 10/31/21 and resigned. Interview on 11/04/21 at 10:42 A.M. with RN #611 revealed she was scheduled to work at the facility on 10/31/21 from 7:00 A.M. to 11:00 A.M. but when she arrived, she was the only nurse on the non- COVID-19 unit when there were usually two nurses, and there was not a nurse on the COVID-19 unit. She revealed she was not able to get everything done on the non-COVID-19 unit so she would not have had time to go to the COVID-19 unit. RN #611 revealed she was never instructed by the Administrator or anyone else to go on the COVID-19 unit as that would have been an infection control issue going back and forth as well as she was not able to get everything done on the non-COVID-19 unit including administering medications and treatments. RN #611 revealed she refused to take the medication cart keys from the previous shift nurse that had worked on the COVID-19 unit as she made it known she was not taking responsibility for the COVID-19 unit as it was unsafe. RN #611 revealed she was unsure the previous shift nurse's name or what that nurse did with the medication cart keys. She revealed the Administrator was aware she was not going onto the COVID-19 unit. Interview on 11/04/21 at 11:05 A.M. with STNA #612 revealed on 10/31/21 from 7:00 A.M. to 7:00 P.M. he was the only staff member that worked on the COVID-19 unit, and there was no nurse. STNA #612 revealed Resident #8 stated he had severe pain to his back and requested his pain medication. STNA #612 revealed Resident #8 moaned out continuously which began mid-morning on 10/31/21. STNA #612 revealed Resident #8 continued to be in severe pain, moaning out continuously and holding his back until 10/31/21 at 7:00 P.M. when RN #609 came on duty. STNA #612 revealed Resident #31 was recently admitted to the facility with a fractured hip. STNA #612 revealed Resident #31 was in pain as he was moaning out and showing signs of discomfort. STNA #612 revealed he knew that Resident #31 could receive [MEDICATION(S)] for his pain but because there was no nurse on the COVID-19 unit. STNA #612 indicated Resident #31 could not be assessed or receive pain medication as he should have. STNA #612 revealed he contacted the Administrator multiple times regarding no nurse and Residents #8 and #31 being in pain, and each time the Administrator stated he was working on getting a nurse. STNA #612 revealed Resident #15 continued to state that he could not breath throughout the shift. STNA #612 revealed he attempted to provide comfort but was concerned as he had no idea how his vital signs were especially his oxygen saturation level. STNA #612 revealed he notified the Administrator and RN #611 of Resident #15's complaint of difficulty breathing, and STNA #612 stated, again, they did nothing. STNA #612 revealed he felt he was stuck on the COVID-19 unit in an unsafe situation with residents in pain and having respiratory issues, and he felt helpless as he could do nothing as he was not a nurse. Interview on 11/08/21 at 4:07 P.M. with the Administrator revealed on 10/29/21 the DON resigned but had given a 30-day notice. The Administrator revealed he knew on 10/29/21 and 10/30/21 the facility still did not have a nurse for the COVID-19 unit for 10/31/21 from 7:00 A.M. to 7:00 P.M. The Administrator revealed on 10/30/21 at approximately 6:00 P.M. he had assigned the DON to cover the COVID-19 unit on 10/31/21 from 7:00 A.M. to 7:00 P.M. and she acknowledged that she would. The Administrator revealed he notified RN Corporate Clinical Coordinator #600 on 10/29/21 that the DON had resigned on 10/29/21, and she had indicated she would be at the facility on 11/01/21 but the administrator did not recall if he informed RN Corporate Clinical Coordinator #600 that they did not have nursing coverage for the COVID-19 unit for 10/31/21 as he had assumed the DON would cover. The Administrator indicated he received a call from STNA #612, who was working on the COVID-19 unit, at approximately 8:00 A.M. that there was not a nurse on the unit as the DON had not arrived. The Administrator revealed he had attempted to contact the DON multiple times but received no return call. The Administrator stated he attempted to contact agencies for a nurse. The Administrator revealed he notified the one nurse in the facility, RN #611, that she would have to administer medication on the non- COVID-19 unit and the COVID-19 unit. The Administrator revealed he was aware the census of the facility was 43 but assumed maybe at the end of the day she would have been able to get to the COVID-19 unit. The Administrator verified he was not aware RN #611 was unable to go to the COVID-19 unit, and he was not aware medications, treatments, or assessments were not completed on 10/31/21 from 7:00 A.M. to 7:00 P.M. The Administrator indicated he was not aware Resident #8 and Resident #31 had not had their pain addressed as he indicated he thought RN #611 was addressing the needs on the COVID-19 unit. The Administrator verified he did not check with RN #611 on 10/31/21 after he had assigned her to go onto the COVID-19 unit as he assumed she was. The Administrator indicated he did not contact RN Corporate Clinical Coordinator #600 as he did not feel she would be able to assist as she lived over three hours away. The Administrator also verified he did not contact RN Corporate Clinical Coordinator #600 regarding guidance regarding nursing services on 10/31/21. The Administrator also verified he did not contact the resident's primary care physicians to notify them there was not a nurse on the unit as he indicated he felt RN #611 was going onto the COVID-19 unit. The Administrator revealed he did contact Regional Director of Operations (RDO) #627 on 10/31/21 at approximately 11:32 A.M. regarding the situation of additional mitigating staffing steps including having RN #611 service the six residents on the COVID-19 unit. The Administrator indicated on 10/31/21 at 5:00 P.M. the DON entered the facility and resigned effective immediately. Review of facility job description titled Director of Nursing Services, dated April 2004, revealed the primary purpose of the DON was to plan, organize, develop, and direct the overall operation of the nursing services in accordance with federal, state, and local standards, guidelines, and regulation that govern our facility and as may be directed by the Administrator to ensure quality care was always maintained. The job description revealed the DON was to coordinate the staffing needs of the nursing services necessary to meet the total nursing needs of the residents including assigning enough licensed nurses. The job description revealed the DON was to perform on call responsibilities as necessary or required and provide direct nursing care as necessary. Review of the staffing procedure titled Mitigate Staffing Shortages, dated 07/28/20 revealed when staffing shortages were occurring, healthcare and employers may need to implement crisis capacity strategies to continue to provide patient care. The procedure revealed the facility was to develop regional plans to identify designated healthcare facilities or alternative care sites with adequate staffing to care for patients with COVID-19. Interventions under the crisis capacity strategies included implement regional plans to transfer patients with COVID-19 to designated healthcare facilities or alternative care sites with adequate staffing. The Administrator had placed a N/A (not applicable) next to this intervention. Review of facility form titled Facility Assessment- V2, dated 01/07/21, revealed the facility average census over the past 12 months was 33. The facility assessment revealed under staffing plan the average number of licensed nurses providing direct care in a 24-hour period was four. The facility assessment did not identify plans to service residents on the COVID-19 unit including a staffing plan. Review of the facility form titled Mitigating Staffing Steps Taken For 10/31/21, completed by the Administrator revealed on 10/30/21 at 5:04 P.M. the Administrator discussed staffing for 10/31/21 with the DON at 6:01 P.M. The Administrator assigned the DON to cover the COVID-19 unit if no staff picked up, and the DON acknowledged she would cover, and at 7:31 P.M. the Administrator had received approval from RDO #627 to offer incentives. The form revealed on 10/31/21 at 8:12 A.M. the Administrator attempted other agencies; at 8:13 A.M. the Administrator informed RN #611 she would have to provide nursing services including medications to residents on the COVID-19 unit in the event another nurse did not pick up; at 8:16 A.M. the Administrator notified the DON to see if she was aware there was only one nurse in the building, and she needed to come into the facility but received no response; at 11:32 A.M. the Administrator notified RDO #627 of the situation and discussed additional mitigation staffing steps including having the agency nurse who was in the building service the six residents on the COVID-19 unit; at 12:00 P.M. the Administrator arrived at the facility, and at 5:00 P.M. the DON entered the kitchen at the facility and informed the Administrator she was quitting effective immediately with no notice. This deficiency substantiates Complaint Number OH 169.

Based on interview, observation, record review, review of facility policy and procedure regarding diabetic management, medication administration, and pain management the facility failed to ensure medications were administered on the COVID-19 unit on 10/31/21 from 7:00 A.M. to 7:00 P.M. resulting in significant medications errors affecting four residents (Resident's #8, #18, #31 and #43) residing on the COVID-19 unit. This resulted in Immediate Jeopardy that caused actual harm for four residents, (Residents #8, #18, #31 and #43) due to the failure to administer significant medication. On 10/31/21 at 7:30 A.M. Resident #8, who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .M., his NPH insulin 11 units SQ before dinner at 5:00 P.M., and an omitted blood glucose level check with coverage with [MEDICATION(S)] insulin 100 units per ml administered per sliding scale at 11:00 A.M. and 4:00 P.M. The failure to administer the medications as ordered resulted in Resident #8's blood sugar on 10/31/21 at approximately 7:30 P.M. registering high when checked at a level of 374 milligrams (mg) per deciliter (dL) requiring administration of 11 units of NPH insulin ordered to be given immediately by Physician Assistant (PA) #602. On 10/31/21 at 10:00 A.M. Resident #18, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] .M., 12:00 P.M. and 5:00 P.M. Medications including [MEDICATION(S)] insulin 100 units per milliliter (ml) injected subcutaneously per sliding insulin were not given. On 10/31/21 at 7:23 P.M. Resident #18's blood sugar was 397 mg dL requiring eight units of regular insulin given immediately per order of PA #602. On 10/31/21 between 7:00A.M. and 7:00 P.M. Resident #8 and Resident #31 were not assessed for pain or provided their ordered pain medications resulting in intolerable pain evidenced by the residents crying and moaning out for an extended time period. Registered Nurse (RN) #609 arrived on duty on 10/31/21 at 7:00 P.M. and observed Resident #8 crying out in severe pain with a pain level of ten on a pain scale of zero to ten. RN #609 indicated Resident #31's pain on 10/31/21 at 8:07 P.M. was a seven on a pain scale of zero to ten. On 10/31/21 Resident #43, who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and [MEDICATION(S)] at 9:00 A.M., 1:00 P.M. and 5:00 P.M. as ordered resulting in the potential for [CONDITION(S)] activity. This affected four of six residents residing on the COVID-19 unit. The facility census was 43. On 11/08/21 at 5:08 P.M., the Administrator and RN Corporate Clinical Coordinator #600 were notified Immediate Jeopardy began on 10/31/21 when the facility only had one nurse, RN #611, who was assigned to the entire resident population of 43 residents and was not able to check blood sugars, or administer any medications including pain medications, anti-[CONDITION(S)], anticoagulant, and insulin per physician orders on the COVID-19 unit on 10/31/21 from 7:00 A.M. to 7:00 P.M. This resulted in a potential for Resident #43 to have [CONDITION(S)] activity, Resident #8 and Resident #31 to have intolerable pain for an extended period and Resident #8's blood sugar to be 374 mg dL on 10/31/21 at approximately 7:30 P.M. requiring a one-time order of NPH insulin of 11 units and Resident #18's blood sugar on 10/31/21 at 7:23 P.M. to be 397 mg dL requiring 8 units of regular insulin. The Immediate Jeopardy was removed on 11/09/21 when the facility implemented the following corrective actions: · Resident #8 was evaluated for pain by Minimum Data Set (MDS)/ RN #623 on 11/03/21 at 11:32 A.M. Care plan for pain was reviewed 11/09/21 at 11:00 A.M. by RN/ MDS Coordinator #622 for Resident #8. Resident #8 was evaluated by the PA #602 and was noted to be stable after receiving insulin late on 11/03/21. Resident #8 received scheduled insulin on 11/08/21 and 11/09/21 per sliding scale and was without signs or symptoms of [CONDITION(S)] or [CONDITION(S)]. Resident #8 received scheduled [MEDICATION(S)] for nerve pain on 11/08/21 and 11/09/21. Resident #8 received scheduled Oxycodone-Acetaminophen (pain medication) 10/325 milligrams (mg) per physician orders on 11/08/21 and 11/09/21. Resident #31 was evaluated by PA #602 on 11/02/21 at approximately 10:00 A.M. and noted to be stable after receiving medications late on 10/31/21. Resident #31 was evaluated on 11/09/21 at 10:06 A.M. by the MDS/ RN #622. Resident #31 refused the [MEDICATION(S)] patch on 11/09/21 at 9:00 A.M. and PA #602 was notified 11/09/21 at 11:00 A.M. Resident #31 is receiving Oxycodone per physician order and has had no uncontrolled pain. Resident #18 was evaluated by PA #602 on 11/02/21 at approximately 10:00 A.M. due to missed insulin. Resident #18 received insulin per sliding scale on 11/03/21. Resident #18 was discharged on [DATE]. Resident #43 was reviewed and did not have any negative outcomes following missed anti-[CONDITION(S)] medications. Review of the corrective action on 11/10/21 at 11:05 A.M. verified it was completed. · Medication Administration Records (MAR's) were reviewed beginning from 11/01/21 by the RN Corporate Clinical Coordinator #600, or designee if any other residents received pain medications, insulin, anti-[CONDITION(S)] and/or anticoagulant late and/or had medications omitted. No insulin, pain medications, anti-[CONDITION(S)] and/or anticoagulants were missed and/or late since 11/08/21. Pain management care plans were reviewed by RN/ MDS #622 and #623 and diabetic care plans were reviewed by RN/ Corporate Float MDS #624 on 11/09/21 from 7:00 A.M. through 3:00 P.M. and updated as necessary. Review of the corrective action on 11/10/21 at 11:45 A.M. verified it was completed. · The medication administration policy was reviewed during the Quality Assurance Performance Improvement (QAPI) meeting on 11/09/21 at 1:30 P.M. In attendance were the Administrator, RN Corporate Clinical Coordinator #600, Medical Director #628, and Regional Director of Operation #627. Review on 11/10/21 at 12:00 P.M. verified the QAPI meeting was conducted on 11/09/21 at 1:30 P.M. · All licensed nurses on duty 11/09/21 at 7:00 A.M. were educated on the medication administration policy with a strong emphasis on medication administration times. PA #602 was notified of missed or late medications on 11/09/21 at 11:00 A.M. by RN Corporate Clinical Coordinator #600, or designee. 100 percent of facility licensed nurses (two nurses on payroll) received education on the medication administration policy by RN/ Clinical Coordinator on from 11/04/21 at 1:00 P.M. to 11/05/21 7:00 A.M. Medication management policy and procedure education was provided to the Director of the Primary Staffing Agency #629 on 11/09/21 at 3:03 P.M. by the Administrator and will be provided to agency nurses prior to being sent to the facility. Any licensed nurses sent to the facility without education validation will receive the education by the RN Corporate Clinical Coordinator #600 upon hire, the Director of Nursing (DON)/designee prior to start of their shift. All newly hired licensed nurses will receive the same education during new hire orientation by RN Corporate Clinical Coordinator #600 or the DON (when hired)/designee. Review of the in-service training verified the training occurred on 11/08/21 at 7:00 P.M., 11/09/21 at 7:00 A.M., 11/09/21 at 3:30 P.M., 11/09/21 at 5:10 P.M., and 11/10/21 at 7:15 A.M. with licensed nurses prior to their beginning of their shift as well as the two facility nurses, Licensed Practical Nurse (LPN) #630 and RN #619. Interview on 11/10/21 at 12:04 P.M. with RN #631 and RN #632 verified they received the training prior to the start of their shift, and they were knowledgeable regarding the medication administration policy and procedure. · Audits five times weekly for one month and then weekly for one month and then monthly for three months will be conducted via observation relative to pain medication administration, insulin administration, anti-[CONDITION(S)] and/or anticoagulants, by the RN Corporate Clinical Coordinator #600, DON (when hired)/designee, of residents on a pain management program and/or insulin to ensure that pain medication, insulin administration, anti-[CONDITION(S)] and/or anticoagulant is completed timely. Any identified issues with pain will be addressed immediately. The results will be submitted to the QAPI committee monthly for review and recommendations. The Administrator is responsible for sustained compliance. Although the Immediate Jeopardy was removed on 11/09/21, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Review of the medical record for Resident #18 revealed an admitted [DATE] and discharge date of [DATE]. Resident #18's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 10/28/21 revealed Resident #18 did not have a care plan regarding management of diabetes. Review of the physician orders for 10/31/21 revealed Resident #18 was to receive [MEDICATION(S)] solution (anticoagulant) 40 mg per 0.4 milliliter (ml) inject subcutaneously ordered for 10:00 A.M., obtain glucose level at 8:00 A.M., 12:00 P.M. and 5:00 P.M. and inject [MEDICATION(S)]-solution 100 units per ml subcutaneously per sliding scale. Review of the October 2021 MAR revealed Resident #18 did not receive any of his ordered medications including his anticoagulant and insulin per sliding scale on 10/31/21 from 7:00 A.M. to 7:00 P.M. Review of the nursing note dated 10/31/21 at 7:23 P.M. and authored by RN #609 revealed a random blood sugar was obtained, and Resident #18's blood sugar was 397 mg dL. The nursing note revealed RN #609 notified PA #602 and received a new order to administer a one-time dose of eight units of regular insulin. Interview on 11/03/21 at 10:37 A.M. and 11/08/21 at 8:27 A.M. with RN Corporate Clinical Coordinator #600 verified Resident #18 did not receive any ordered medications on 10/31/21 from 7:00 A.M. to 7:00 P.M. including his blood glucose level checked at 8:00 A.M., 12:00 P.M. and 5:00 P.M. and insulin administered per sliding scale as there was not a nurse on the COVID-19 unit. RN Corporate Clinical Coordinator #600 verified Resident #18's blood sugar was taken on 10/31/21 at 7:23 P.M. and was elevated at 392 mg dL requiring a one-time dose of regular insulin. RN Corporate Clinical Coordinator #600 verified Resident #18 did not have a care plan regarding management of diabetes. Interview on 11/03/21 at 11:45 A.M. with PA #602 revealed on 10/31/21 at approximately 7:30 P.M. she was notified by RN #609 that there had not been a nurse on the COVID-19 unit on 10/31/21 from 7:00 A.M. to 7:00 P.M. The facility only had an aide on the unit, and Resident #18 did not receive any medications during this time including his insulin. PA #602 revealed RN #609 checked Resident #18's blood sugar. His blood sugar was 397 mg dL, and she ordered a one-time dose of eight units of regular insulin to be given immediately. 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission physician orders for October 2021 revealed Resident #8 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M., NPH insulin suspension 100 units per ml give 11 units subcutaneously in the evening before dinner for diabetes ordered for 5:00 P.M., check blood glucose level and administer insulin [MEDICATION(S)] 100 units per ml by injecting subcutaneously per sliding scale before meals for diabetes ordered for 11:00 A.M. and 4:00 P.M., Oxycodone-Acetaminophen 10-325 mg tablet by mouth every four hours as needed for pain, and Acetaminophen 325 mg tablet administer two tablets every four hours as needed for mild pain. Review of the October 2021 MAR revealed Resident #8 received Oxycodone- Acetaminophen 10-325 mg tablet by mouth on 10/31/21 at 5:54 A.M. for a pain level of seven on a pain scale of zero to ten. Resident #8 did not receive any further Oxycodone-Acetaminophen until 10/31/21 at 7:15 P.M. when his pain level was documented as a ten on a pain scale of zero to ten. The MAR revealed Resident #8 did not receive any of his ordered medication including insulin and pain medications on 10/31/21 from 7:00 A.M. to 7:00 P.M. and did not have his blood glucose level checked as ordered. Review of the admission assessment labeled Nursing Comprehensive Evaluation V1-V13 for Resident #8 dated 10/28/21 and completed by RN #618 revealed Resident #8 was currently having pain and had pain in the last five days. Resident #8 revealed his pain was in his lower back and bilateral heels. Resident #8 revealed his pain was an eight on a pain scale of zero to ten. Resident #8 revealed his pain got as bad as a 10 on a pain scale of zero to ten. Review of the care plan dated 10/28/21 revealed Resident #8 was at risk for pain. Interventions included anticipate resident's need for pain relief as needed and respond immediately to any complaint of pain, and notify physician if interventions were unsuccessful or if current complaint was a significant change from resident's experience of pain. Resident #8 did not have a care plan related to management of diabetes and interventions. Review of the admission Brief Interview for Mental Status (BIMS) dated 10/29/21 revealed Resident #8 was cognitively intact with a BIMS score of a 15. Review of the nursing note dated 10/31/21 at 8:29 P.M. and authored by RN #609 revealed she completed a random blood sugar check, and Resident #8's blood sugar was 374 mg dL. RN #609 notified PA #602 and received an order to give NPH insulin 11 units now for coverage of the elevated blood sugar. Interview on 11/03/21 at 10:37 A.M. and 11/08/21 at 8:27 A.M. with RN Corporate Clinical Coordinator #600 verified there was only one aide on the COVID-19 unit, and there was not a nurse on 10/31/21 from 7:00 A.M. to 7:00 P.M. RN Corporate Clinical Coordinator #600 verified Resident #8 did not receive any medications or blood sugar checks that were scheduled between 7:00 A.M. to 7:00 P.M. including Resident #8's insulin, and pain medication. The last Oxycodone-Acetaminophen 10-325 mg as needed was given on 10/31/21 at 5:54 A.M., and he had not received any further Oxycodone-Acetaminophen until 10/31/21 at 7:15 P.M. per RN #609. RN Corporate Clinical Coordinator #600 revealed the DON walked out, and the Administrator tried to get a nurse but was unable to. Interview on 11/03/21 at 11:45 A.M. with PA #602 revealed on 10/31/21 at approximately 7:30 P.M. she was notified by RN #609 that there had not been a nurse on the COVID-19 unit on 10/31/21 from 7:00 A.M. to 7:00 P.M. The facility only had a state tested nurse aide ( STNA) on the unit, and Resident #8 did not receive any medications during this time. PA #602 revealed she was aware Resident #8 did not receive any pain medications all day and was in pain when RN #609 had arrived on duty. PA #602 revealed Resident #8 had chronic back pain and received medications as needed to control his pain. PA #602 revealed RN #609 administered his pain medication when she arrived on the unit at approximately 7:00 P.M. PA #602 also revealed she was aware Resident #8 had not had his blood glucose level checked or any ordered insulin on 10/31/21 from 7:00 A.M. to 7:00 P.M. PA #602 revealed RN #609 checked Resident #8's blood glucose level, and it was 374 mg dL. She ordered NPH insulin 11 units to be given right away and recheck Resident #8's blood glucose level. Interview on 11/03/21 at 2:09 P.M. with Resident #8, who is cognitively intact, revealed he did not receive any of his pain medications all day one day when he was on the COVID-19 unit and was in severe pain to the point he thought he was dying from the pain. Review of the Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #8 revealed it was still in progress. Interview on 11/04/21 at 11:05 A.M. with STNA #612 revealed on 10/31/21 from 7:00 A.M. to 7:00 P.M. he was the only staff member that worked on the COVID-19 unit, and there was not a nurse. STNA #612 revealed Resident #8 stated he had severe pain to his back and requested his pain medication. STNA #612 revealed Resident #8 moaned continuously which began mid-morning on 10/31/21. STNA #612 revealed he contacted the Administrator multiple times regarding no nurse and Resident #8 moaning in pain, and each time STNA #612 revealed the Administrator stated he was working on getting a nurse. STNA #612 revealed Resident #8 continued to be in severe pain, moaning continuously and holding his back until 10/31/21 at 7:00 P.M. when RN #609 came on duty. STNA #612 revealed he felt terrible as there was nothing, he could do except try to make Resident #8 more comfortable. Interview on 11/04/21 at 9:57 A.M. with RN #609 revealed Resident #8 was in severe pain when she arrived on the COVID-19 unit on 10/31/21 at 7:00 P.M. as Resident #8 was crying and had a pain level assessed as a ten on a pain scale of zero to ten. RN #609 revealed she reviewed the MAR and was aware Resident #8 had not received any Oxycodone-Acetaminophen since early that morning at approximately 5:00 A.M. RN #609 revealed she medicated Resident #8 with Oxycodone-Acetaminophen 10-325 mg tablet per his as needed order and notified PA #602. 3. Review of the medical record for Resident #31 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders revealed on 10/31/21 Resident #31 had the following orders: [MEDICATION(S)] patch 4 percent apply to affected area due to left femur fracture which was to be applied at 9:00 A.M. Resident #31 also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission assessment labeled Nursing Comprehensive Evaluation, dated 10/30/21, completed by RN #621 revealed Resident #31 was not having pain and had not had pain in the last five days. Review of the October 2021 MAR revealed Resident #31 had not received any of his medications including pain medications ordered on 10/31/21 from 7:00 A.M. to 7:00 P.M. Resident #31 had a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR revealed Resident #31 was given [MEDICATION(S)] on 10/30/21 at 8:37 P.M. for a pain level of seven on a pain scale of zero to ten that was effective. The MAR revealed Resident #31 was given [MEDICATION(S)] on 10/31/21 at 6:32 A.M., and it was documented Resident #31's pain level was an eight on a pain scale of zero to ten, and the [MEDICATION(S)] was ineffective for Resident #31's pain. Review of the nursing notes dated 10/31/21 at 8:07 P.M. and authored by RN #609 revealed she assessed the effectiveness of the [MEDICATION(S)] that was provided to Resident #31 on 10/31/21 at 6:32 A.M. and revealed the [MEDICATION(S)] was ineffective as Resident #31's pain level was a seven on a pain scale of zero to ten. There was no documented evidence in the nursing notes of any intervention provided for Resident #31's pain level being assessed as a seven on a pain scale of zero to ten. There was no documented evidence he received additional pain management medication or that PA #602 was notified regarding his pain level being a seven. Review of the care plan dated 11/01/21 revealed Resident #31 did not have a care plan regarding pain management. Review of the BIMS dated 11/01/21 revealed Resident #31 had severe cognitive impairment. Review of the Admission MDS 3.0 assessment dated [DATE] revealed it was still in progress. Interview on 11/04/21 at 11:05 A.M. with STNA #612 revealed on 10/31/21 from 7:00 A.M. to 7:00 P.M. he was the only staff member that worked on the COVID-19 unit, and there was not a nurse. STNA #612 revealed Resident #31 was recently admitted to the facility with a [CONDITION(S)]. STNA #612 revealed Resident #31 was in pain as he was moaning and showing signs of discomfort. STNA #612 revealed he knew Resident #31 could receive medication for his pain but because there was no nurse on theCOVID-19 unit, Resident #31 could not be assessed or receive pain medication as he should have. STNA #612 revealed he contacted the Administrator multiple times regarding no nurse and Resident #31 being in pain, and each time the Administrator stated he was working on getting a nurse. STNA #612 revealed he was frustrated as he knew Resident #31 was in pain. STNA #612 stated he was a STNA and was unable to give medications, and all he could do was try to make Resident #31 comfortable by repositioning him in bed for comfort . Observation and interview on 11/09/21 at 11:24 A.M. revealed Resident #31 was up in the recliner visiting with his daughter and displayed no signs of pain or discomfort. Resident #31 revealed his pain level was about a four on a pain scale of zero to ten. Resident #31 could not provide any information regarding concerns of pain while on the COVID-19 unit. Resident #31's daughter revealed she was not able to visit when he was on the COVID-19 unit and was not able to communicate with him on the phone, so she had no information regarding his pain management while residing on the COVID-19 unit. Interview on 11/09/21 at 1:17 P.M. with RN #609 verified Resident #31 had not received any medication on 10/31/21 from 7:00 A.M. to 7:00 P.M. as there was no nurse. She verified she remembered Resident #31 moaning when she came in to work, but she could not provide any further details as she could not remember. 4. Review of the closed medical record for Resident #43 revealed an admitted [DATE] and a discharge date on 11/02/21. Resident #43's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 10/28/21 revealed Resident #43 was at risk for [CONDITION(S)] disorder. Interventions included labs as ordered and [CONDITION(S)] precautions. Review of the physician orders for 10/31/21 revealed Resident #43 had orders including: [MEDICATION(S)] (anti-[CONDITION(S)]) 500 mg tablet for [CONDITION(S)] ordered for 9:00 A.M., and [MEDICATION(S)] (anti-[CONDITION(S)]) 300 mg capsule by mouth for [CONDITION(S)] ordered for 9:00 A.M., 1:00 P.M., and 5:00 P.M. Review of the October 2021 MAR revealed Resident #43 did not receive any of the medications including anti-[CONDITION(S)] [CONDITION(S)] medications ordered to be administered on 10/31/21 from 7:00 A.M. to 7:00 P.M. Interview on 11/03/21 at 10:37 A.M. and 11/08/21 at 8:27 A.M. with RN Corporate Clinical Coordinator #600 verified Resident #43 did not receive any of the medications ordered to be administered on 10/31/21 from 7:00 A.M. to 7:00 P.M. as there was not a nurse on the COVID-19 unit. Review of the facility policy titled Pain Management, dated July 2021, revealed the facility would evaluate and identify a resident for pain, determine the type, location and severity and develop a care plan for pain management. The policy revealed staff were to observe a resident for pain indicators including moaning, crying, other vocalization, and body posture as guarding or protecting an area. The policy revealed the nursing assistant would communicate to the licensed nurse when a resident was experiencing pain. The policy revealed the licensed nurse would communicate a new onset of pain to the physician. The staff would implement the care plan and administer interventions for pain. Review of the facility policy labeled Medication Administration, dated November 2021, revealed the facility failed to implement their policy as the resident medications were to be administered in an accurate, safe, timely, and sanitary manner. The policy revealed do not administer medications until the discrepancy was resolved. The policy revealed medications were to be administered within 60 minutes of the scheduled time. Review of the facility policy labeled Diabetic Management, dated November 2021, revealed diabetic management involves both preventative measures and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy also revealed anti-diabetic agents including insulin were to be administered per physician order. This deficiency substantiates Complaint Number OH 169.

Based on observation, record review, review of facility policy and procedure related to pain management and interviews with facility staff the facility failed to address two residents' (Resident's #8 and #31) request for pain management resulting in Resident #8 and Resident #31 experiencing intolerable pain that caused them to cry out over an extended time period on 10/31/21 on the 7:00 A.M. to 7:00 P.M. shift. On 10/31/21 from 7:00 A.M.to 7:00 P.M. the facility had knowledge that one nurse, RN #611, was assigned to the entire resident population of 43 residents. RN #611 did not provide any care to the residents residing on the COVID-19 unit including assessment of pain for two residents (Residents #8 and #31) from 7:00A.M. through 7:00 P.M. This resulted in Immediate Jeopardy that resulted in actual harm on 10/31/21 when the only staff member on the COVID-19 unit was STNA #612 who indicated Resident #8 began mid-morning moaning out continuously and complaining of back pain. STNA #612 revealed on 10/31/21 Resident #31 also was crying out throughout the day and showing signs of pain due to his recent left hip replacement. STNA #612 revealed Resident #8 and Resident #31's pain was not assessed or addressed by a nurse as the facility did not have a nurse on the COVID-19 unit on 10/31/21 from 7:00 A.M. to 7:00 P.M. STNA #612 revealed he had notified the Administrator of the COVID-19 unit not having a nurse and of Resident #8 and #31's pain. STNA #612 revealed Residents #8 and #31 remained in intolerable pain as the residents were not evaluated for their pain or provided pain medications as ordered. Registered Nurse (RN) #609 indicated she arrived on duty on 10/31/21 at 7:00 P.M. and Resident #8 was crying out in severe pain as his pain level was a ten on a pain scale of zero to ten. RN #609 revealed Resident #31's pain on 10/31/21 at 8:07 P.M. was a seven on a pain scale of zero to ten. This affected two of six residents on the COVID-19 unit. The facility census was 43. On 11/08/21 at 5:08 P.M., the Administrator and RN Clinical Coordinator #600 were notified Immediate Jeopardy began on 10/31/21 when the facility only had one nurse in the facility that did not address any needs of any of the residents on the COVID-19 unit including assessing Resident #8 and Resident #31's ongoing complaints of pain and administering pain medications as ordered from 7:00 A.M. to 7:00 P.M resulting in Resident #8 and Resident #31 having intolerable pain for an extended period of time. The Immediate Jeopardy was removed on 11/09/21 when the facility implemented the following corrective actions: · Resident #8 was evaluated for pain on 11/09/21 at 11:32 A.M. by the Minimum Data Set (MDS)/ RN #623. Resident #8's pain was verified on 11/10/21 at 10:20 A.M. as being evaluated and form labeled, Pain Evaluation-V2 was completed on 11/09/21. Pain medication was administered per physician order, and Resident #8 was not having excruciating pain at this time. · Resident #8's care plan was reviewed and updated on 11/09/21 at 11:00 A.M. by RN/ MDS Coordinator #622. Resident #8's care plan for pain was verified on 11/10/21 at 10:25 A.M. that it had been revised on 11/09/21. · Resident #31 was evaluated on 11/09/21 by RN/ MDS #622 at 10:06 A.M. Resident #31's pain was verified on 10/10/21 at 10:28 A.M. as being evaluated and form labeled, Pain Evaluation-V2 was completed on 11/09/21. Resident #31 received pain medication as scheduled. Resident #31 refused his [MEDICATION(S)] patch on 11/09/21 at 9:00 A.M., and Physician Assistant (PA) #602 was notified on 11/09/21 at 11:00 A.M. · Resident #31's care plan was reviewed and updated as necessary on 11/09/21 at 11:00 A.M. by RN/ Corporate Float MDS #624. Resident #31's care plan was verified on 11/10/21 at 10:30 A.M. that it had been initiated on 11/09/21 as Resident #31 previously did not have a care plan for pain. · All residents receiving pain management have the potential for uncontrolled pain. Pain evaluations were completed on 11/09/21 from 07:00 A.M. until 12:30 P.M. by RN/MDS #623 and #622 on residents receiving pain management, and any identified issues had their primary care physicians notified. On 11/10/21 at 10:29 A.M. pain evaluations were verified that they were completed on 11/09/21 and a sample of residents were reviewed including Resident's #5, #8, #23, #31 and #37 and no issues were noted. · Pain management policy and procedure were reviewed by Quality Assurance Performance Improvement (QAPI) meeting on 11/09/21 at 1:30 P.M. In attendance were Administrator, RN/ Clinical Coordinator #600, Medical Director #628, and Regional Director of Operation (RDO) #627. Review on 11/10/21 at 10:32 A.M. revealed the QAPI meeting had occurred on 11/09/21 at 1:30 P.M. · All Licensed nurses (three nurses) on duty 11/09/21 at 07:00 A.M. were re-educated on the pain management policy and procedure by RN/ Clinical Coordinator #600. All licensed staff will receive the same education prior to next scheduled shift by RN/ Clinical Coordinator #600 or designee. All facility licensed nurses (one nurse) have been educated as of 11/09/21 at 3:00 P.M. The other facility licensed nurse had a voicemail left by RN/ Regional Clinical Coordinator #625 and will be educated prior to the start of her next shift. (The facility only has two licensed nurses on staff, LPN #630, and RN #619). Any agency staff assigned to the facility will receive the same education prior to the start of their shift by the RN/Clinical Coordinator #600 or designee. All new hires will receive education by RN/ Clinical Coordinator #600 or designee on pain policy and procedure during new hire orientation. Pain management policy and procedure education was provided to the Director of the Primary Staffing Agency #629 on 11/09/21 at 3:03 P.M. by the Administrator and will be provided to agency nurses prior to sending to the facility. Any licensed nurses sent to the facility without education validation will receive the education by the RN/ Clinical Coordinator #600, Director of Nursing (when hired)/designee prior to start of their shift. Review of in-service training records on 11/08/21 at 7:00 P.M., 11/09/21 at 7:00 A.M., 11/09/21 at 3:30 P.M., 11/09/21 at 5:10 P.M. and 11/10/21 at 7:15 A.M. revealed licensed nurses prior to their beginning of their shift as well as the two facility nurses (RN #619 and #630) had been in-serviced. Interview on 11/10/21 at 12:04 P.M. with RN #631 and RN #632 verified they received the training prior to the start of their shift, and they were knowledgeable regarding the pain management policy and procedure. · Audits five times weekly, for one month, then weekly for one month, then monthly for three months, will be conducted of medication administration records relative to pain medication administration by the RN/ Clinical Coordinator #600, DON (when hired)/designee, of residents on a pain management program to ensure that pain medication is administered timely. Audits five times weekly, for one month, then weekly for one month, then monthly for three months, will be conducted via pain interviews and observations by the RN/ Clinical Coordinator #600, DON (when hired)/designee, of residents on a pain management program to ensure pain is controlled. Any identified issues with pain will be addressed immediately. The results will be submitted to the QAPI committee monthly for review and recommendations. The administrator is responsible for sustained compliance. Review on 11/10/21 at 12:15 P.M. of the pain management audit revealed it was conducted on 11/09/21 from 07:00 A.M. until 12:30 P.M. by RN/MDS #623 and #622. Although the Immediate Jeopardy was removed on 11/09/21, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Review of the medical record for Resident #8 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission physician orders for October 2021 revealed Resident #8 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. as Resident #8's pain level was a seven on a pain scale of zero to ten. Resident #8 did not receive any further Oxycodone- Acetaminophen until 10/31/21 at 7:15 P.M. when his pain level was documented as a ten on a pain scale of zero to ten. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Resident #8 did not receive his [MEDICATION(S)] 100 mg one capsule by mouth in the evening as ordered for nerve pain. Review of the admission facility form labeled, Nursing Comprehensive Evaluation V1-V13 for Resident #8 dated 10/28/21 and completed by RN #618 revealed Resident #8 was currently having pain and had pain in the last five days. Resident #8 revealed his pain was in his lower back and bilateral heels. Resident #8 revealed his pain was an eight on a pain scale of zero to ten. Resident #8 revealed his pain got as bad as a ten on a pain scale of zero to ten. Review of the care plan dated 10/28/21 revealed Resident #8 was at risk for pain. Interventions included anticipate resident's need for pain relief as needed and respond immediately to any complaint of pain, and notify physician if interventions were unsuccessful or if current complaint was a significant change from resident's experience of pain. Review of the admission Brief Interview for Mental Status (BIMS) dated 10/29/21 revealed Resident #8 was cognitively intact with a BIMS score of a 15. Review of the Admission Minimum Data Set (3.0) assessment dated [DATE] for Resident #8 revealed it was still in progress. Interview on 11/03/21 at 10:37 A.M. and 11/08/21 at 8:27 A.M. with RN Corporate Clinical Coordinator #600 verified there was only one aide on the COVID-19 unit and there was not a nurse on 10/31/21 from 7:00 A.M. to 7:00 P.M. RN Corporate Clinical Coordinator #600 verified Resident #8 received Oxycodone- Acetaminophen 10-325 milligram as needed on 10/31/21 at 5:54 A.M. and had not received any further Oxycodone- Acetaminophen until 10/31/21 at 7:15 P.M. (over 13 hours later). RN Corporate Clinical Coordinator #600 revealed the Director of Nursing (DON) walked out, and the Administrator tried to get a nurse to cover the COVID-19 unit but was unable. Interview on 11/03/21 at 11:45 A.M. with PA #602 revealed on 10/31/21 at approximately 7:30 P.M. she was notified by RN #609 that there had not been a nurse on the COVID-19 unit on 10/31/21 from 7:00 A.M. to 7:00 P.M. and that the facility only had an aide on the unit and residents residing on the unit did not receive any medications during this time. PA #602 revealed she was aware Resident #8 did not receive any pain medications all day and was in severe pain when RN #609 arrived on duty at 7:00 P.M. PA #602 revealed Resident #8 had chronic back pain and received medications routinely to control his pain. PA #602 revealed RN #609 administered his pain medication when she arrived on the unit at approximately 7:00 P.M. Interview on 11/03/21 at 2:09 P.M. with Resident #8 who is cognitively intact with a BIMS of 15 revealed he did not receive any of his pain medications all day one day when he was on the COVID-19 unit and was in severe pain to the point he thought he was dying from the pain. Interview on 11/04/21 at 9:04 A.M. with the Administrator revealed on 10/31/21 at approximately 8:00 A.M. he received a call from STNA #612 stating STNA #612 was the only staff on the COVID-19 unit and there was not a nurse. The Administrator revealed he only had one other nurse in the facility, RN #611, who was assigned on the non- COVID-19 unit so he was unable to pull her to the COVID-19 unit right away. The Administrator revealed he attempted to contact the director of nursing (DON) multiple times, as well as facility and agency staffing to fill in but was unable to find anyone. The Administrator revealed on 10/31/21 at 5:00 P.M. the DON came into the facility and cleaned out her office and resigned effective immediately. The Administrator revealed he assumed RN #611 had attempted at least at the end of her shift to go onto the COVID-19 unit to administer medications and really did not realize she had not administered any of the residents' medications on 10/31/21 that were scheduled from 7:00 A.M. to 7:00 P.M. and the Administrator indicated was not aware Resident #8 had not received his pain medication. Interview on 11/04/21 at 10:42 A.M. with RN #611 revealed she was only scheduled at the facility on 10/31/21 from 7:00 A.M. to 11:00 A.M. but when she arrived, she was the only nurse on the non- COVID-19 unit when there were usually two nurses, and there was not a nurse on the COVID-19 unit. She revealed she was not able to get everything completed on the non-COVID-19 unit, so she would not have had time to go to the COVID-19 unit. RN #611 revealed she was never instructed by the Administrator or anyone else to go on the COVID-19 unit as that would have been an infection control issue going back and forth as well as she was not able to get everything done on the non-COVID-19 unit including administering medications. She indicated the Administrator was aware she was not going onto the COVID-19 unit. Interview on 11/04/21 at 11:05 A.M. with STNA #612 revealed on 10/31/21 from 7:00 A.M. to 7:00 P.M. he was the only staff member that worked on the COVID-19 unit, and there was no nurse. STNA #612 revealed Resident #8 stated he had severe pain to his back and requested his pain medication. STNA #612 revealed Resident #8 moaned out continuously in pain which began mid-morning on 10/31/21. STNA #612 revealed he contacted the Administrator multiple times regarding no nurse and Resident #8 moaning in pain and each time the Administrator just stated he was working on getting a nurse. STNA #612 revealed Resident #8 continued to be in severe pain, moaning out continuously and holding his back until 10/31/21 at 7:00 P.M. when RN #609 came on duty. STNA #612 revealed he felt terrible and there was nothing he could do except try to reposition Resident #8 and make him more comfortable. Interview on 11/4/21 at 9:57 A.M. with RN #609 revealed Resident #8 was in severe pain when she arrived on the COVID-19 unit on 10/31/21 at 7:00 P.M. as Resident #8 was crying and had a pain level assessed as a ten on a pain scale of zero to ten. RN #609 revealed she reviewed and was aware Resident #8 had not received any Oxycodone-Acetaminophen since early that morning at approximately 5:00 A.M. because there had not been a nurse on 10/31/21 from 7:00 A.M. to 7:00 P.M. on the COVID-19 unit. RN #609 revealed she medicated Resident #8 with Oxycodone-Acetaminophen 10-325 milligram (mg) tablet per his as needed order and notified Physician Assistant (PA) #602. 2. Review of the Operative Report dated 10/26/21 and authored per Orthopedic Surgeon #620 revealed Resident #31 had presented in the emergency department after a fall and sustained a left femoral neck fracture requiring a left hip hemiarthroplasty which was completed on 10/26/21. Review of the medical record for Resident #31 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders for Resident #31 revealed he had an order dated 10/29/21 for [MEDICATION(S)] 50 mg give 0.5 tablet by mouth every 12 hours as needed for pain for up to five days, an order dated 10/30/21 for [MEDICATION(S)] patch four percent to apply to affected area topically once a day and remove as scheduled. Resident #31 had orders dated 11/02/21 for Tylenol 325 mg give two tablets by mouth every six hours as needed for pain and Oxycodone HCL five mg by mouth four times a day for pain to left hip fracture. Review of the admission Nursing Comprehensive Evaluation dated 10/30/21 completed by RN #621 revealed Resident #31 was not having pain and had not had pain in the last five days. Review of the October 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. that was not administered. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. for a pain level of seven on a pain scale of zero to ten which was effective. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and it was documented Resident #31's pain level was an eight on a pain scale of zero to ten, and the [MEDICATION(S)] was ineffective for Resident #31's pain. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing notes dated 10/31/21 at 8:07 P.M. and authored by RN #619 revealed she assessed the effectiveness of the [MEDICATION(S)] that was provided to Resident #31 on 10/31/21 at 6:32 A.M. and on 10/31/21 at 8:07 P.M. and revealed the [MEDICATION(S)] was ineffective as Resident #31's pain level was a seven on a pain scale of zero to ten. There was no documented evidence in the nursing notes of any intervention that was provided for Resident #31's pain level being assessed as a seven on a pain scale of zero to ten. There was no documented evidence he received additional pain management medication or that the PA #602 was notified regarding his pain level being a seven on a pain scale of zero to ten. Review of the care plan dated 11/01/21 for Resident #31 revealed Resident #31 did not have a care plan regarding pain management. Review of the physician orders dated 11/02/21 revealed Resident #31 had a new order for Oxycodone HCL 5 mg give one tablet by mouth four times a day for left hip fracture pain. Review of the BIMS dated 11/01/21 revealed Resident #31 had severe cognitive impairment. Review of the Admission MDS 3.0 assessment dated [DATE] revealed it was still in progress. Interview on 11/04/21 at 11:05 A.M. with STNA #612 revealed on 10/31/21 from 7:00 A.M. to 7:00 P.M. he was the only staff member that worked on the COVID-19 unit, and there was not a nurse. STNA #612 revealed Resident #31 was recently admitted to the facility with a left hip fracture. STNA #612 revealed Resident #31 was in pain as he was moaning and showed signs of discomfort throughout the day on 10/31/21. STNA #612 indicated he knew Resident #31 had an order to receive pain medication but because there was no nurse on the COVID-19 unit, Resident #31 could not be assessed or receive pain medication as needed. STNA #612 revealed he contacted the Administrator multiple times regarding not having a nurse on the unit and Resident #31's pain and each time STNA #612 indicated the Administrator stated he was working on getting a nurse. STNA #612 revealed he was frustrated as he knew Resident #31 was in pain, and he was only an STNA and unable to give medications and all he could do was try to make Resident #31 comfortable by repositioning him for comfort. Observation and interview on 11/09/21 at 11:24 A.M. revealed Resident #31 was up in the recliner visiting with his daughter. He displayed no signs of pain or discomfort. Resident #31 indicated his pain level was about a four on a pain scale of zero to ten. Resident #31 could not provide any information regarding if he had any concerns regarding his pain not being assessed or managed on the COVID-19 unit. Resident #31's daughter revealed she had been not able to visit when he was on the COVID-19 unit and was not able to communicate with him on the phone, so she had no information regarding his pain management when Resident #31 resided on the COVID-19 unit. Interview on 11/10/21 at 1:17 P.M. with RN #609 revealed she remembered Resident #31 moaning on 10/31/21 when she came in but could not remember any details except that she had spoken to PA #602 about looking at his pain management and changing the [MEDICATION(S)] to something else as she felt it was ineffective. Review of the facility policy titled Pain Management, dated July 2021, revealed the facility would evaluate and identify a resident for pain, determine the type, location and severity and develop a care plan for pain management. The policy revealed staff were to observe a resident for pain indicators including moaning, crying, other vocalization, and body posture as guarding or protecting an area. The policy revealed the nursing assistant would communicate to the licensed nurse when a resident was experiencing pain. The policy revealed the licensed nurse would communicate any new onset of pain to the physician. The staff would implement the care plan and administer interventions for pain. This deficiency substantiates Complaint Number OH 169.

Based on observation, record review and staff interview, the facility failed to ensure one resident (Resident #66) did not develop avoidable stage two and stage three pressure ulcers which resulted in harm. This affected one of three residents reviewed for pressure ulcers. The facility identified three residents in the facility with pressure ulcers. The facility census was 67. Findings include: Resident #66 had been admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. The quarterly minimum data set 3.0 (MDS) assessment dated [DATE] revealed Resident #66 was alert and oriented and cognitively intact as evidenced by a brief interview for mental status (BIMS) score of 14. Resident #66 required extensive assistance and the physical assist of two plus persons for bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #66 was always incontinent of bowel and bladder. The plan of care related to impaired skin integrity originally dated on 09/29/11 and updated and revised up through 11/01/12 indicated the following: Resident #66 was at risk for impaired skin integrity due to multiple medical diagnoses, incontinence of bowel and bladder, impaired mobility, (friction/shearing from use of a sliding board for transfers), altered sensation, poor circulation and abnormal lab value of [MEDICATION NAME] to indicate poor protein level. Interventions in place included to improve co- morbidities, evaluate and document skin condition, make sure adult briefs were not binding, prevalon boot to left foot, notify physician of change in condition, provide diet to improve nutrition, provide supplements as tolerated, provide wound treatment as ordered, therapeutic mattress, therapeutic chair pad, specialty bed mattress, lift sheet on bed/chair and turn and position in bed /chair every two hours as tolerated. Laboratory results for Resident #66 dated 08/15/12 indicated an [MEDICATION NAME] level of 3.4 (normal 3.5-5.5) and a Pre-[MEDICATION NAME] level dated 11/06/12 of 4 ( normal 16-38), both were indicative of poor protein levels. The plan of care last updated 11/14/12 related to nutrition stated Resident #66 was ordered a regular no added salt diet, 30 milliliters of Prostat ( high protein supplement) three times a day, and eight ounces of milk with meals. Record review of the skin assessment dated [DATE] indicated Resident #66 at risk for skin breakdown as evidenced by the Braden score of 16. The quarterly assessment dated [DATE] revealed the resident as at risk with a score of 15. Braden score dated 11/04/12 was 14 (at risk 15-18, moderate risk 13-14, high risk, 10-12 and very high risk was equal to or under 9). Review of the admission "Resident - Data Collection" sheet dated 09/26/12 indicated Resident #66 did not have any open or pressure areas on admission to the facility. The Skin Condition reports documented Resident #66's pressure areas as follows: #1. Gluteal fold On 10/21/12 an abrasion was documented to the left posterior upper thigh in the gluteal fold and measured at 2.0 centimeter (cm.) x 2.0 cm. x 1.5 cm. as a stage III, (full thickness tissue loss slough present) pink in color, with scant amount (amt.) of serous drainage, [MEDICATION NAME] tissue present. The 10/29/12 measurements were 3.0 cm. x 2.4 cm. x 0.7cm. in size, stage III, scant amt of serous drainage, beefy red, less than 25% of skin intact, tender and documented deterioration. The 11/04/12 measurements were 2.0 cm. x 2.2 cm. x 1.5 cm. stage III, with necrotic tissue and red yellow and black tissue present, moderate amt of serous drainage, white/gray/yellow slough with black eschar. Documented wound deterioration. The 11/08/12 measurements were 3.30 cm. x 3.4 cm. x 2.4 cm. in size, stage III, large amt thin clear drainage, skin not intact, adherent soft black eschar, deteriorated wound documented. On 11/15/12, observation of wound dressing change revealed the area had declined to 4.6 cm x 4.8 cm x 3.9 cm prior to debridedment directed by by the certified nurse practitioner(CNP). The CNP stated to Resident #66 the wound had declined and was deeper and wider with more necrotic tissue present. A mesalt ([MEDICATION NAME] agent to assist with wound healing) dressing was packed into the wound. Tunneling (a passageway of tissue destruction under the skin surface) was present at 12:00 o'clock area 0.5 cm. and at 6:00 o'clock area at 1.0 cm. #2. Left calf First documented 10/29/12 stage II with measurements of 2.0 cm. x 3.5 cm. x closed, black in color, no drainage. No treatment ordered. On 11/04/12 deteriorated to stage III, red with yellow slough, measured 0.9 cm. x 1.9 cm. x 0.1 cm. Silver alginate with [MEDICATION NAME] with foam ordered and changed daily and as needed. On 11/8/12 the wound was stage III, scant amt. of serous drainage, with improvement. On 11/15/12 the wound was stage III, scant amt. serous drainage improved. CNP stated wound resurfaced, granulation tissue observed in center of wound. Area left open as per order. An interview with the director of nursing on 11/15/12 at 9:35 A.M. verified the abrasion to the gluteal fold had occurred from her incontinence brief and the use of the sliding board for transfers. Review of the facility's policy and procedures for transfers indicated for the use of the Sliding Board Transfer revealed the resident should scoot across on the sliding board to the wheel chair surface assisting as necessary and the staff was to check the resident's skin at an appropriate and convenient time to identify any trauma that may have occurred. An investigation summary dated 10/22/12 was provided by the facility. The statement indicated in relation to the open area on Resident #66's left upper posterior thigh (gluteal fold) the resident used a sliding board or a Hoyer lift for transfers and wore an adult incontinence brief. The director of nursing had stated the resident was at risk for shearing during transfers and the incontinence brief may rub against the skin. No further investigation was provided. An investigation summary dated 11/15/12 for a pressure area to the left posterior calf was provided by the facility. The summary stated on 10/28/12 Resident #66 had a fluid filled area to the back of her left calf. An interview with the resident by the director of nursing revealed the area occurred during transfer of the resident by staff using the Hoyer lift. The documentation provided by the facility indicated no treatment had been initiated to the area for eight days, at which time the wound had deteriorated. An inservice had been provided to nursing staff by the director of therapy on 09/08/2011 with education and signatures provided. No recent education available. An interview with the director of therapy #76 on 11/15/12 at 2:53 P.M. revealed he had assisted staff in use of the transfer board for Resident #66 when he had overheard a staff member state she did not know how to use the board.