Every finding on record at The Pavilion at Piketon

Based on record review, review of facility policy titled Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating, and interviews, the facility failed to appropriately report an allegation of resident to resident abuse to the proper agencies. This affected one resident (Resident #73) out of three reviewed for abuse. The facility census was 102. Findings include: Review of the medical record for Resident #73 revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: diabetes mellitis type II, post-traumatic stress disorder, muscle weakness, Bipolar disorder, psychoactive substance abuse, altered mental status, dysphagia, lack of coordination, low back pain, alcohol abuse, nicotine dependence, hypertension, and gastro-esophageal reflux disease. This resident is alert and oriented and has minimal cognitive deficits according to the Minimum Data Set (MDS) assessment completed on 03/22/25. Review of nursing notes from 4/12/25 at 10:35 A.M. revealed Resident #73 reported feeling threatened by the resident located across the hall. Resident #73 stated that Resident #62 had made threatening comments towards him, including saying he doesn't like him. More seriously Resident #73 claims that Resident #62 has stated there is a hit out on him and threatened to beat him up or kill him or would have his buddies do it. Resident #73 also expressed concern that Resident #62 possesses a knife. Resident #73 states this is all over him having a girlfriend and Resident #62 not having one. Activity Director #111 immediately let the I wing nurse aware of the situation, the I wing nurse and Activity Director #111 immediately went down to Resident #62's room to ask Resident #62 if he did have a knife on his person, and the resident stated no. But the nurse had seen the knife located in his basket. Nurse immediately notified the Director of Nursing of the situation and both residents are being monitored at this time. The knife was removed and locked up in the activity directors office. This was written by Activity Director #111. Review of nursing note dated 4/12/2025 at 11:35 A.M. revealed Activity Director #111 had offered to show/ move Resident #73 to a new hallway after the incident had occurred and resident stated no he did not want to move, just hope nothing happens. This was written by Activity Director #111. Interview with Resident #73 on 04/14/25 at 02:52 P.M. stated another resident had a knife and threatened him. Resident stated he felt afraid at the time, and is still fearful. Interview with the Director of Nursing (DON) on 04/15/25 at 02:40 P.M. verified in light of the above notes from 04/12/25, both residents were both offered a room change and both declined. She agreed this incident should have been reported as this was a qualifying event under reportable incidents by the facility. Interview with Activities Director #111 on 04/15/25 at 03:24 P.M. revealed Resident #73 reported he felt threatened by another resident who had a knife. Stated the resident was fearful after the incident so she brought him to the activities room for a few hours. She stated she had notified the DON and was told to offer both residents a room change away from each other, which both declined. Review of facility policy titled Identifying Types of Abuse last revised in September 2022, revealed mental and verbal abuse include but not limited to threatening gestures or fear of a person or place. Review of the Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigation last revised in September 2022, revealed if resident abuse is suspected it will be reported immediately as required by current regulations. Review of current Self Reported Incidents on 04/16/25 at 03:31 P.M. revealed this incident has not been created as of this time. Law Enforcement has not been notified as well.

Based on record reviews and staff interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was accurately completed. This affected one resident (#71) out of the six residents reviewed for PASARR during the annual survey. The facility census was 102. Findings include: Record review for Resident #71 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included epilepsy, seizures, mood disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/07/25, revealed the resident was assessed to have intact cognition. Review of the residents physicians orders from 06/06/24 through 06/13/24 revealed the resident was ordered Buspar (an anti-anxiety medication) and Sertraline (an anti-depressant medication). Review of the PASARR, signed as completed on 06/13/24, revealed the resident was assessed to have not been ordered any psychotropic medications (anti-anxiety, anti-depressant, anti-psychotic, or mood stabilizers) in the past six months. Interview with the Director of Nursing (DON) on 04/16/25 at 2:40 P.M. confirmed the PASARR for Resident #71 had been completed inaccurately as the resident had been ordered psychotropic medication within the six months prior to the completion of the PASARR.

Based on observation, interview and record review the facility failed to provide timely podiatry care and services to Resident #3. This affected one (Resident #3) of four residents reviewed for activities of daily living. The facility census was 102. Findings include: Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses including infection/inflammation reaction due to internal joint prosthesis, osteoarthritis, paint in left knee and major depressive disorder. Review of the physician orders for Resident #3 revealed an order received on admission to see podiatry as needed. Review of the Medicare 5 day Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was cognitively intact and required partial to moderate assistance to complete activities of daily living. Review of the nursing progress notes for Resident #3 revealed no documentation of the condition of Resident #3 toe nails. The progress notes did not indicate Resident #3 had been seen by a podiatrist. Review of the plan of care dated 01/25/25 revealed Resident #3 required assistance with activities of daily living. Observations on 04/14/25 at 3:06 P.M. and 04/15/25 at 10:12 A.M. revealed Resident #3 toe nails (all 10) were long, yellow and thick. The toe nails were pressing against the skin of the next toe. Interview on 04/14/25 at 3:06 P.M. with Resident #3 revealed he would like to have his toe nails trimmed and treated. Resident #3 stated he had not seen the foot doctor (podiatrist) since he had been at the facility. Interview on 04/16/25 at 3:24 P.M. with Licensed Practical Nurse (LPN) #19 confirmed Resident #3 toe nails were long, yellow and thick. LPN #19 confirmed Resident #3 had not been seen by podiatry since admission.

Based on staff interview, record review, observation, and document review the facility failed to ensure residents were free of significant medication errors when staff failed to prime an insulin pen for Resident #90. This affected one (Resident #90) of five residents reviewed for medication administration. The facility census was 102. Findings include: Record review of Resident #90 revealed an admitted [DATE] with pertinent diagnoses of: sepsis, osteomyelitis, type two diabetes mellitus, hypertension, acquired absence of right and left lower leg below knee. Review of the 02/06/25 modification of admission and medicare five day Minimum Data Set (MDS) assessment revealed the resident is cognitively intact and uses a wheelchair to aid in mobility. Review of Physician Order dated 02/04/25 revealed Humalog injection solution 100 unit/milliliter (insulin Lispro) inject as per sliding scale if 150-200= 3 units; 201-250= 6 units; 251-300= 9 units; 301-350=12 units; 351-400=15 units; 401+= 18 units notify Nurse Practitioner, subcutaneously before meals and and bedtime for diabetes mellitus. Review of a Physician Order dated 02/04/25 revealed Insulin Lispro (one unit dial) 100 unit/milliliter solution pen injector inject seven units subcutaneously before meals and at bedtime related to type tow diabetes mellitus. Observation on 04/15/25 at 5:02 P.M. revealed Licensed Practical Nurse #11 (LPN) took Resident #90 blood sugar and it was 168 mg/Dl milligrams per deciliter. LPN #11 dialed the insulin Lispro pen to 10 units for seven units scheduled and three units for sliding scale. LPN #11 did not prime the insulin pen prior to administration to Resident #90. Interview with LPN #11 on 04/15/25 at 5:10 P.M. LPN #11 verified she did not prime the insulin pen prior to administering Resident #90 insulin. Review of the Humalog Kwikpen (insulin Lispro) instructions for use copyright 2007 revealed to prime before each injection. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with needle pointing up. Push the dose knob until it stops and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeating priming step no more than four times. If you still do not see insulin, change the needle and repeat priming.

Based on staff interview, record review, observation, and document review, the facility failed to appropriately clean a blood glucose monitoring machine between patient uses. This affected one (Resident #90) of five residents reviewed for medication administration. This had the potential to affect three Residents (Resident #90, #298, and #303) who resided on the E hallway and received blood sugar glucose monitoring. The facility census was 102. Findings include: Record review of Resident #90 revealed an admitted [DATE] with pertinent diagnoses of: sepsis, osteomyelitis, type two diabetes mellitus, hypertension, acquired absence of right and left lower leg below knee. Review of the 02/06/25 modification of admission and medicare five day Minimum Data Set (MDS) assessment revealed the Resident is cognitively intact and uses a wheelchair to aid in mobility. Review of Physician Order dated 02/04/25 revealed Humalog injection solution 100 unit/milliliter (insulin Lispro) inject as per sliding scale if 150-200= 3 units; 201-250= 6 units; 251-300= 9 units; 301-350=12 units; 351-400=15 units; 401+= 18 units notify Nurse Practitioner, subcutaneously before meals and and bedtime for diabetes mellitus. Review of a Physician Order dated 02/04/25 revealed Insulin Lispro (one unit dial) 100 unit/milliliter solution pen injector inject seven units subcutaneously before meals and at bedtime related to type tow diabetes mellitus. Observation on 04/15/25 at 4:19 P.M. revealed Licensed Practical Nurse #11 (LPN) took Resident #303 blood sugar with an Assure Platinum blood glucose monitoring machine. LPN #11 used an alcohol wipe to clean the glucose machine. Observation on 04/15/25 at 4:45 P.M. revealed LPN #11 went into Resident #90 room to take his blood sugar. The Surveyor intervened and had her clean the blood glucose machine with a bleach wipe prior to taking Resident #90 blood glucose level. Interview with LPN #11 on 04/15/25 at 4:47 P.M. verified she was unaware that shared use glucose machines should be cleaned with bleach prior to Resident use to prevent blood borne pathogen transmission. The facility identified there was no blood borne communicable diseases for the Resident receiving blood glucose monitoring on the E Hall. Review of the revised 09/24 facility provided Arkray technical brief cleaning and disinfecting the assure platinum blood glucose monitoring system revealed the machine may only be used for testing multiple patients when standard precautions and the manufacturers disinfecting procedures are followed. The disinfecting procedure is needed to prevent the transmission of bloodborne pathogens. Arkray has tested and validated the durability and functionality of the Assure Platinum meter with the most commonly used EPA-registered wipes. Our testing confirmed the wipes listed below will not damage the functionality or performance of the meter through 3,650 cleaning and disinfecting cycles. ARKRAY recommends using these wipes to clean and disinfect the Assure Platinum meter: Clorox Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels with Bleach, Super Sani-Cloth Germicidal Disposable Wipe, CaviWipes, or Microdot Bleach Wipe.

Based on medical record review, observation, staff interview, and facility policy review, the facility failed to develop and implement comprehensive and individualized interventions to prevent the onset of joint contractures for Resident #38. Actual harm occurred on 01/10/24 when Resident #38, who was admitted to the facility without contractures was assessed to have developed contractures to the third and fourth fingers on the left and right hands which caused pain upon range of motion for the resident due to a lack of interventions to prevent the contractures from occurring. This affected one (Resident #38) of one resident reviewed for range of motion. The facility census was 84. Findings include: Review of the medical record for Resident #38 revealed an admitted [DATE] with diagnoses including fracture of lumbar vertebra, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus, morbid obesity, hypertension, hyperlipidemia, chronic kidney disease, atrial fibrillation, congestive heart failure, encephalopathy, osteoarthritis, anemia, anxiety disorder, major depressive disorder. Review of the care plan for Resident #38 initiated 10/12/23 revealed the plan did not include the resident's risk for development of contractures and/or an individualized range of motion program for the resident. Review of the occupational therapy (OT) evaluation for Resident #38 dated 10/13/23 revealed the resident's range of motion to the right upper extremity was within normal limits, and the left upper extremity range of motion was within normal limits. A goal of therapy was for Resident #38 to tolerate passive range of motion to bilateral upper extremities to prevent the development of contractures. Review of the Minimum Data Set (MDS) for Resident #38 dated 11/06/23 revealed the resident was cognitively intact and had no functional limitations in range of motion. Review of the OT treatment note for Resident #38 dated 01/10/24 revealed therapy staff were providing manual joint mobilization to the resident's hands to increase joint mobility and/or range of motion. Review of the OT treatment note for Resident #38 dated 01/15/24 revealed OT was providing manual joint mobilization to increase joint mobility and/or range of motion in bilateral upper extremities to aid in contracture control. Further review revealed the treatment note was edited on 01/17/24 at 1:10 P.M. by OT Aide #174 to reflect the addition of the range of motion exercises. Review of the care plan for Resident #38 dated 01/17/24 revealed the resident had an alteration in musculoskeletal status related to contractures to the fingers of her right and left hand. Interventions included continue therapy as ordered, monitor for pain, give analgesics as ordered, monitor for side effects and effectiveness, monitor skin to right and left hand for skin breakdown. Observation on 01/16/24 at 12:34 P.M. revealed Resident #38 was holding her hands in fists, and her long and jagged nails were cutting into the palm of her hands. The resident was unable to open her hands completely on request. Observation on 01/16/24 at 1:35 P.M. with Registered Nurse (RN) #203 revealed Resident #38's hands were clenched tightly. RN #203 attempted to provide range of motion to the resident's fingers and the resident began screaming out in pain. Interview on 01/16/24 at 1:35 P.M. with RN #203 confirmed Resident #38's fingers were stiff and contracted and the resident verbalized pain when the nurse attempted to provide passive range of motion to the resident's hands. Interview on 01/17/24 at 12:05 P.M. with Occupational Therapist (OT) #178 confirmed Resident #38 was placed on therapy caseload upon admission and they had continued to work with the resident approximately three times weekly since admission. OT #178 confirmed Resident #38 had entered the facility without contractures, but the resident had developed contractures to both hands which were first identified on 01/10/24. OT #178 confirmed therapy had provided range of motion exercises three days per week. Interview on 01/22/24 at 10:51 A.M. with Nurse Practitioner (NP) #500 confirmed Resident #38 had developed contractures to the third and fourth fingers to her hands since the resident's admission to the facility. Interview on 01/22/24/ at 2:28 P.M. with the Director of Nursing (DON) confirmed the Resident #38 was admitted to the facility without contractures and the resident had developed contractures to both hands which were first identified on 01/10/24. The DON further confirmed the facility had not developed an individualized range of motion program or implemented other interventions to prevent contracture formation. Review of the facility policy titled Prevention of Decline in Range of Motion dated 09/29/22 revealed the facility in collaboration with the medical director, DON and OT consultant should establish and utilize a systemic approach for prevention of decline in range of motion, including assessment, appropriate care planning and preventative care.

Based on medical record review, observation, staff interview, review of hospital progress notes, review of the facility policy, and review of manufacturer's guidelines, the facility failed to ensure Resident #70 was provided adequate and necessary interventions to prevent falls including a fall with injury and failed to ensure post-fall investigations were completed for Resident #69. This affected two residents (Resident #69 and #70) of four residents reviewed for falls. The facility census was 84. Actual harm occurred on 11/29/23 when Resident #70, who was moderately cognitively impaired, at risk for falls and care planned to require the use of hipsters (a type of garment worn to help reduce the risk of injuries from a fall, such as hip fractures, through impact-absorbing foam pads over the critical fracture area) sustained a fall with increased pain and subsequent left hip fracture when not wearing the hipsters as care planned. As a result of the fall, the resident was hospitalized and required surgical intervention to repair the hip fracture. Findings include: 1. Review of the medical record for Resident #70 revealed an admitted [DATE] with diagnoses including history of displaced intertrochanteric fracture of the right femur, dementia, muscle weakness, and repeated falls. Review of the Minimum Data Set (MDS) assessment for Resident #70 dated 11/30/23 revealed the resident was moderately cognitively impaired. Review of the care plan for Resident #70 dated 02/03/23 revealed the resident was at risk for falls related to history of falls and history of fracture. Interventions included the resident should wear hipsters at all times. Review of the nursing progress note for Resident #70 dated 11/29/23 timed at 11:11 P.M. revealed the resident was sitting in a chair in the common area and got up and fell in front of the chair. After the fall, Resident #70 was complaining of left hip pain and was unable to stand. Review of the nursing progress note for Resident #70 dated 11/30/23 timed at 12:31 A.M. revealed the resident was sent to the hospital via ambulance for a post-fall evaluation. Review of the facility fall investigation for Resident #70 dated 11/30/23 revealed the investigation did not indicate whether or not the resident was wearing hipsters per the plan of care at the time of the fall. Review of the hospital discharge summary for Resident #70 dated 12/03/23 revealed the resident was admitted to the hospital on 11/30/23 with a left hip fracture after sustaining a mechanical fall. The resident underwent surgical repair of the fracture on 12/01/23. Observation on 01/22/24 at 1:08 P.M. revealed Resident #70 was resting in bed and was not wearing hipsters. There were no hipsters visible in the resident's room. Interview on 01/22/24 at 1:08 P.M. with State tested Nursing Assistant (STNA) #125 confirmed Resident #70 was not wearing hipsters and did not have hipsters visible in his room. STNA #125 further confirmed she was not aware of the need for Resident #70 to wear hipsters. Interview on 01/22/24 at 2:05 P.M. with the Director of Nursing (DON) confirmed Resident #70 was at risk for falls with injury and his care plan included the intervention of wearing hipsters at all times to prevent risk of hip fractures if the resident fell . The DON further confirmed that the intervention of wearing hipsters at all times remained a current intervention on the resident's care plan. Telephone interview on 01/22/24 at 2:54 P.M. with Licensed Practical Nurse (LPN) #169 confirmed she was working the night Resident #70 fell and fractured his hip. LPN #169 confirmed Resident #70 was supposed to wear hip protectors at all times, but stated he was not wearing them at the time of his fall on 11/29/23. Review of the undated manufacturer's recommendations for hip protectors revealed the garment was worn to protect against hip injuries from falls. The hip protectors had sewn-in foam pads which sat over the hip bones to help absorb energy from falls. Review of the facility policy titled Fall Interventions Program dated 09/29/22 revealed each resident would be assessed for fall risk and would receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. 47987 2. Review of the medical record for Resident #69 revealed an admitted [DATE] with diagnoses including end stage renal disease, seizure disorder, type two diabetes mellitus, and acute respiratory failure with hypoxia. Review of the MDS assessment for Resident #69 dated 10/27/23 revealed the resident was moderately cognitively impaired and used a wheelchair for mobility. Review of the progress notes for Resident #69 revealed the resident sustained falls on 10/31/23 and 11/02/23. Review of the medical record for Resident #69 revealed the record did not include any type of investigations regarding the resident's falls on 10/31/23 and 11/02/23. Interview on 01/22/24 at 1:35 P.M. with the DON confirmed the facility had not completed a post-fall investigations regarding Resident #69's falls on 10/31/23 and 11/02/23. Review of the facility policy titled Fall Prevention Program dated 09/29/2022 revealed when a resident falls the facility would complete a post-fall investigation.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure target behaviors were identified and monitored in conjunction with the use of anti-psychotic medications. This affected four (Residents #15, #54, #59, and #76) of 22 facility-identified residents with orders for anti-psychotic medications. The facility census was 84. Findings include: 1. Review of the medical record for Resident #15 revealed an admitted [DATE] with diagnoses including bipolar disorder, dementia with other behavioral disturbances, and hallucinations. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #15 dated 12/20/23, revealed the resident was mildly cognitively impaired and received anti-psychotic medication on a routine basis. Review of the physician's orders for Resident #15 revealed an order dated 11/30/23 for Seroquel (an anti-psychotic medication) 300 milligrams (mg) once a day in the evening related to bipolar disorder. Review of the care plan for Resident #15 initiated 09/07/23 revealed the care plan did not include documentation regarding target behaviors being treated by use of the anti-psychotic medication. Interview on 01/18/24 at 8:00 A.M with the Director of Nursing (DON) confirmed the facility had not identified target behaviors or monitored behaviors related to the use of anti-psychotic medication for Resident #15. 2. Review of the medical record for Resident #54 revealed an admitted [DATE] with diagnoses including dementia with other behavioral disturbances, psychosis, and anxiety disorder. Review of the annual MDS assessment for Resident #54 dated 12/06/23 revealed the resident was cognitively impaired and received anti-psychotic medication on a routine basis. Review of the physician's orders for Resident #54 revealed an order dated 07/26/23 for the Zyprexa 7.5 mg once daily for unspecified psychosis. Review of the care plan for Resident #54 initiated 12/06/21 revealed the care plan did not include documentation regarding target behaviors being treated by use of the anti-psychotic medication. Interview on 01/18/24 at 8:00 A.M with the DON confirmed the facility had not identified target behaviors or monitored behaviors related to the use of anti-psychotic medication for Resident #54. 3. Review of the medical record for Resident #76 revealed an admitted [DATE] with diagnoses including schizophrenia, bipolar disorder, and post-traumatic stress disorder (PTSD). Review of the admission MDS assessment for Resident #76 dated 11/07/23 revealed the resident was cognitively intact and received anti-psychotic medication on a routine basis. Review of the physician's orders for Resident #76 revealed an order dated 11/07/23 for loxapine succinate 55 mg twice daily for schizophrenia. Review of the care plan for Resident #76 initiated 11/01/23 revealed the care plan did not include documentation regarding target behaviors being treated by use of the anti-psychotic medication. Interview on 01/18/24 at 8:00 A.M with the DON confirmed the facility had not identified target behaviors or monitored behaviors related to the use of anti-psychotic medication for Resident #76. 32654 4. Review of the medical record for Resident #59 revealed an admitted [DATE] with diagnoses including dementia with behavioral disturbance, diabetes mellitus, drug induced subacute dyskinesia, psychosis, major depressive disorder, insomnia, and anxiety disorder. Review of the physician's orders for Resident #59 revealed an order dated 07/25/23 for Risperdal 0.25 mg and 0.5 mg once daily for psychosis. Review of the care plan for Resident #59 initiated 08/07/21 revealed the care plan did not include documentation regarding target behaviors being treated by use of the anti-psychotic medication. Interview on 01/22/24 at 2:35 P.M with the DON confirmed the facility had not identified target behaviors or monitored behaviors related to the use of anti-psychotic medication for Resident #59 Review of the facility policy titled Unnecessary Drugs-Without Adequate Indications for Use undated revealed the facility would manage each residents' drug regimen and would monitor the medications to promote or maintain the residents highest practicable mental, physical and psychosocial well-being free from unnecessary drugs.

Based on observation and staff interview the facility failed to maintain a clean and functional environment with evidence of poor repair to five rooms that required wall repairs, room heater repairs, and painting. This affected five residents in rooms numbered B-1, B-5, B-8, B-12, and F-64. The facility census was 84. Findings include: Observation on 01/17/24 at 2:30 P.M. of Room B-12 with the Administrator revealed a large hole in the wall between the outside window and the wall heater. Cold air from outside was blowing into the room through the hole. Areas behind both beds had exposed dry wall and other exposed areas from missing paint with large holes in the drywall observed. The vent screen on the heating unit was visibly rusty and unpainted. Observation on 01/17/24 at 2:35 P.M. of Room B-8 with the Administrator revealed there were large, unrepaired holes in the drywall behind both resident beds and holes under the clock and across the room in the middle of the wall. There were some areas of exposed dry wall between the beds. Observation on 01/17/24 at 2:40 P.M. of Room B-5 with the Administrator revealed there were two large water stains on the ceiling above the sink. The vent screen on the heating unit was visibly rusty and unpainted. Observation on 01/17/24 at 2:45 P.M. of Room B-1 with the Administrator revealed there was a large area of stained flooring under the resident's bed. The vent screen on the heating unit was visibly rusty and unpainted. Observation on 01/17/24 at 2:52 P.M. of Room #F-64 with the Administrator revealed the metal cover on the heating unit was not properly installed and was leaning against the wall. Dry wall was exposed in multiple areas where the paint was peeling away. Interview on 01/17/24 at 3:00 P.M. with the Administrator confirmed the area identified during the observations of Rooms B-1, B-5, B-8, B12, and F-64 needed to be repaired. This deficiency represents non-compliance investigated under Complaint Number OH00149963.

Based on medical record review, resident representative interview, staff interview, and facility policy review, the facility failed to ensure resident representatives were notified of significant changes in resident status. This affected one (Resident #78) of 22 sampled residents. The facility census was 84. Findings include: Review of the medical record for Resident #78 revealed an initial admitted [DATE] with diagnoses including cerebrovascular accident (CVA) with right-sided hemiplegia, osteoarthritis, subarachnoid hemorrhage, frontal lobe and executive function deficit following CVA, major depressive disorder, anxiety disorder, migraine, obstructive sleep apnea, hypertension, and hyperlipidemia. Review of the plan of care for Resident #78 dated 08/03/23 revealed the resident was at risk for impaired nutritional status related to hypertension, left hip arthroplasty, CVA, gastrostomy without tube feeding, hypertension, hyperlipidemia, obesity and weight loss. Interventions included the following: give medications for hypertension as ordered, monitor vital signs as ordered, hold medications and notify physician per parameters, give nutritional supplements as ordered, if resident shows signs/symptoms of choking notify physician and/or speech therapy (ST), monitor labs as ordered, report results to physician, provide diet as ordered, weigh monthly due to weight being stable. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #78 dated 11/06/23 revealed the resident had a severe cognitive deficit. The resident was coded for presence of a significant unplanned weight loss with a body weight of 176 pounds. Review of the weight note for Resident #78 dated 11/08/23 revealed the resident's weight was 175.5 pounds indicating a 27.8-pound weight loss in 60 days. Review of the weight note for Resident #78 dated 01/07/24 revealed the resident's weight was 177 pounds, indicating the resident had a 28-pound weight loss since admission. The resident's weight had remained stable, and the resident accepted meals and supplements. Review of the medical record for Resident #78 revealed it did not include documentation regarding notification to the resident's representative of the resident's significant weight loss of 28 pounds since admission. Interview on 01/16/24 at 3:48 P.M. with the Resident #78's representative confirmed the representative was not notified of the resident's significant weight loss. Interview on 01/17/24 at 3:36 P.M. with the Director of Nursing (DON) confirmed Resident #78's representative was not notified of the resident's significant weight loss. Review of the facility policy titled Notification of Changes dated 09/22/22 revealed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification.

Based on medical record review and staff interview the facility failed to ensure the accuracy of resident assessments. This affected two (Residents #15 and #60) of 22 sampled residents. The facility census was 84. Findings include: 1. Review of the medical record for Resident #60 revealed an admitted [DATE] with diagnoses including quadriplegia, acute respiratory failure, aphasia, dysphagia, and severe protein calorie malnutrition Review of the care plan for Resident #60 dated 09/08/23 revealed the resident had an order for hospice care due to terminal diagnoses of intracranial hemorrhage. Interventions included the following: allow resident time and the opportunity to discuss his situation as needed, check with resident to see if he/she would like clergy visits, hospice care to be provided by hospice agency of resident's or family's choice, refer family to grieving support groups as needed, resident to be kept comfortable and as pain free as medically possible. Review of the quarterly MDS assessment for Resident #60 dated 12/14/23 revealed the resident had a moderate cognitive deficit. The assessment was coded negatively for the resident receiving hospice services. Review of the monthly physician orders for January 2024 for Resident #60 revealed the resident was admitted to hospice services with a diagnosis of intracranial hemorrhage. Interview on 01/22/24 9:37 A.M. with the Administrator confirmed the quarterly MDS for Resident #60 dated 12/14/23 was inaccurate related to the resident's enrollment with hospice services. The Administrator confirmed the resident had been receiving hospice services since admission to the facility. 42728 2. Review of the medical record for Resident #15 revealed an admitted [DATE] with diagnoses including bipolar disorder, dementia with other behavioral disturbances, and history of falling. Review of the nurse progress note for Resident #15 dated 11/10/23 revealed the resident was found lying on the right side on the floor in the dining area with no injuries noted. Review of the discharge return anticipated MDS assessment for Resident #15 dated 11/11/23 revealed the resident was coded to have had no falls since the prior assessment. Interview on 01/18/24 at 9:35 A.M. with MDS Nurse #199 confirmed Resident #15 had fallen while in the facility on 11/10/23, and the MDS assessment dated [DATE] had not been accurately coded to reflect the fall.

Based on medical record review and staff interview, the facility failed to ensure resident Pre-Admission Screening and Resident Review (PASARR) documents were accurate regarding resident current conditions and diagnoses and were completed when appropriate. This affected two (Residents #25 and #59) of four residents reviewed for PASARR documents. The census was 84. Findings include: 1.Review of the medical record for Resident #59 revealed an admitted [DATE] with diagnoses including diabetes mellitus type II, drug induced subacute dyskinesia, depression, seizures, hypertension, and anxiety. Further review of the medical record revealed a diagnosis of unspecified psychosis was added for Resident #59 on 05/23/22. Review of the Minimum Data Set (MDS) assessment for Resident #59 dated 01/13/23 revealed the resident was severely impaired for cognition. Review of the PASARR document for Resident #59 dated 07/31/21 revealed it did not include any psychiatric diagnoses for the resident. Interview on 01/22/24 at 2:28 P.M. with the Administrator confirmed the facility should have completed a new PASARR for Resident #59 upon the addition of a new psychiatric diagnosis on 05/23/22. 32654 2. Review of the medical record for Resident #25 revealed an initial admitted [DATE] with the latest readmitted [DATE] with diagnoses including polyneuropathy, diabetes mellitus, protein calorie malnutrition, anxiety disorder, Down's Syndrome, hypercalcemia, unstageable pressure ulcer to left hip, dislocation of left shoulder, gastro-esophageal reflux disease, anemia and psoriasis. Review of the PASARR for Resident #25 dated 05/09/23 revealed it was good for 180 days. Review of the quarterly MDS assessment for Resident #25 dated 11/28/23 revealed the resident had a severe cognitive deficit. Review of the medical record for Resident #25 revealed it did not include an updated PASARR for the resident. The only PASARR on file for Resident #25 was the one dated 05/09/23. Interview on 01/18/24 at 9:59 A.M. with the Administrator confirmed the facility had not completed a PASARR for resident since the one dated 05/09/23.

Based on medical record review and staff interview, the facility failed to ensure comprehensive care plans were developed and implemented to reflect the need for care in the area of Post Traumatic Stress Disorder (PTSD) and Preadmission Screening and Resident Review (PASARR) recommendations. This affected one (Residents #76) of 22 residents reviewed for care planning. The facility census was 84. Findings include: Review of the medical record for Resident #76 revealed an admitted [DATE] with diagnoses including schizophrenia, bipolar disorder, anxiety, and PTSD. Review of the admission Minimum Data Set (MDS) assessment for Resident #76 dated 11/07/23 revealed the resident was cognitively intact. Review of the Notice of Level II PASARR Outcome for Resident #76 dated 10/16/23 revealed based on the information provided in the Level II assessment and current records, Resident #76 met inclusion criteria for serious mental illness with diagnoses of schizophrenia, bipolar disorder, nicotine dependence, anxiety disorder, and PTSD. Specialized services and support nursing facility staff were required to provide included supportive counseling from nursing facility staff, skills training, ongoing evaluation of the effectiveness of current psychotropic medications on target symptoms, mental health counseling, behaviorally based treatment plan, and structured therapeutic activities. Review of the active care plans for Resident #76 initiated 11/01/23 revealed there was not a plan of care in place that addressed the specialized services and support detailed in the residents Level II PASARR assessment nor a care plan that addressed the resident's needs related to PTSD. Interview on 01/22/24 at 9:20 A.M. with the Director of Nursing (DON) confirmed there were no care plans in place addressing the care of Resident #76 related to the Level II PASARR assessment or the resident's PTSD diagnosis.

Based on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure staff provided assistance with nail care and routine shaving for dependent residents. This affected two (Residents #38 and #78) of four residents reviewed for activities of daily living (ADLs). The facility census was 84. Findings Include: 1. Review of the medical record for Resident #38 revealed an admitted [DATE] with diagnoses including fracture of lumbar vertebra, cardiac arrest, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus, morbid obesity, hypertension, constipation, gastro-esophageal reflux disease, hyperlipidemia, chronic kidney disease, atrial fibrillation, congestive heart failure, osteoarthritis, anemia, anxiety disorder, and major depressive disorder. Review of the plan of care for Resident #38 dated 10/26/23 revealed the resident had a self-care deficit related to COPD. Interventions included the following: therapy evaluation and treat as needed, refuses care/risk and benefits with encouragement given, set-up bath items and put out clothes as needed, toileting with one assist, transfers with one assist and shave daily as needed. Review of the Minimum Data Set (MDS) assessment for Resident #38 dated 11/06/23 revealed the resident was cognitively intact. Review of the mood and behavior section of the MDS revealed the resident displayed verbal behaviors directed towards others, behaviors not directed towards others and rejection of care. Review of the progress notes for Resident #38 dated 10/12/23 to 01/17/24 revealed there was no documentation regarding refusal of care. Observation on 01/16/24 at 12:34 P.M. of Resident #38 revealed the resident was holding her hands in fists and her long and jagged fingernails were cutting into the palm of her hands. The resident was unable to open her hands completely on request. Observation on 01/17/24 at 9:30 A.M. of Resident #38 revealed the resident's fingernails were long and jagged with visible debris underneath and she had untrimmed hairs to her chin. Observation on 01/17/24 at 1:45 P.M. of Resident #38 revealed the resident's fingernails were long and jagged with visible debris underneath and she had untrimmed hairs to her chin. Interview on 01/17/24 at 1:47 P.M. with State tested Nursing Assistant (STNA) #163 confirmed Resident #38's fingernails were long and jagged with visible debris underneath and should be trimmed and cleaned. STNA #163 further confirmed Resident #38's chin hair was long and needed to be trimmed. Review of the facility policy titled Grooming a Resident's Facial Hair dated 2017 revealed it was the practice of the facility to assist residents with grooming facial hair to help maintain proper hygiene as per current standards of practice. 2. Review of the medical record for Resident #78 revealed an admitted [DATE] with diagnoses including cerebrovascular accident (CVA) with right sided hemiplegia, osteoarthritis, nontraumatic subarachnoid hemorrhage, frontal lobe and executive function deficit following CVA, major depressive disorder, anxiety disorder, migraine, nicotine dependence, obstructive sleep apnea, hypertension, and hyperlipidemia. Review of the plan of care for Resident #78 dated 08/15/23 revealed the resident had a self-care deficit related to CVA, history of fracture, hemiplegia, impaired mobility, incontinence, pain, poor health management, weakness and osteoarthritis. Interventions included staff to assist with grooming and hygiene and to provide nail care weekly and as needed. Review of the MDS assessment for Resident #78 dated 11/06/23 revealed the resident had a severe cognitive deficit. Observations on 01/17/24 at 8:19 A.M. and 10:45 A.M. of Resident #78 revealed the resident's fingernails were long with visible debris underneath. Interview on 01/17/24 at 12:45 P.M. with the Administrator confirmed Resident #78's fingernails were long with visible debris underneath and staff should clean and trim the resident's nails. Review of the facility policy titled Nail Care dated 2023 revealed routine cleaning and inspection of nails would be provided during ADL care on an ongoing basis. Routine nail care included trimming and filing on a regular schedule. Nail care should be provided between scheduled occasions as the need arises. This deficiency represents non-compliance investigated under Complaint Number OH00149963.

Based on medical record review, observation, staff interview, facility policy review, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure pressure ulcers were thoroughly assessed and failed to ensure treatments for pressure ulcers were completed as ordered. This affected one (Resident #57) of five residents reviewed for pressure ulcers. The facility census was 84. Findings include: Review of the medical record for Resident #57 revealed an initial admitted [DATE] with the latest readmission of 11/07/23 with diagnoses including severe protein calorie malnutrition, chronic respiratory failure, severe morbid obesity, diabetes mellitus, chronic obstructive pulmonary disease (COPD), stage IV pressure ulcer sacral region, chronic kidney disease, hypertension, hyperlipidemia, and congestive heart failure. Review of the admission assessment for Resident #57 dated 06/20/23 revealed the resident was admitted to the facility with an unstageable pressure ulcer to the sacrum measuring 1.5 centimeters (cm) by 1.0 in length by 0.5 cm in width. The assessment did not include any additional description of the wound. Review of the readmission assessment for Resident #57 dated 09/06/23 revealed the resident was readmitted to the facility with a stage IV pressure ulcer to the sacrum measuring 8.0 cm in length by 6.0 cm in width by 0.5 cm in depth, a suspected deep tissue issues (SDTI) to the left lateral foot measuring 1.0 cm, and an unstageable pressure ulcer to the right heel measuring 4.5 cm in length by 4.6 cm in width. The assessment did not include any additional description of the wounds. Review of the plan of care for Resident #57 dated 09/12/23 revealed the resident was at risk for skin breakdown related to impaired mobility, stage IV pressure ulcer wound to the sacrum and stage IV pressure ulcer to the right heel. Interventions included the following: low air loss mattress with lateral supports, observe skin for redness or open areas, notify the nurse, observe skin with showers/care, notify nurse of any new areas of skin breakdown, off-loading boots, may remove for hygiene and skin checks, pressure reducing/relieving cushion to chair, supplements per order, treat left distal lateral foot as ordered, weekly head to toe skin assessment, document and report abnormal findings to physician. Review of the readmission assessment for Resident #57 dated 11/07/23 revealed the resident was readmitted with wounds and to see the full description. The area on the assessment for detailed wound documentation was blank. Further review of the medical record revealed it did not include an assessment of Resident #57's wounds upon readmission to the facility. Review of the pressure ulcer risk assessment for Resident #57 dated 11/08/23 revealed the resident was at risk for skin breakdown. Review of the weekly pressure ulcer assessment for Resident #57 dated 11/14/23 revealed the resident had a stage IV pressure ulcer to the sacrum which measured 1.4 cm in length by 0.6 cm in width by 0.1 cm in depth. The resident had an area to the right heel which measured 3.8 cm in length by 4.1 cm in width. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the weekly pressure ulcer assessment for Resident #57 dated 11/21/23 revealed the stage IV pressure ulcer to the resident's sacrum measured 2.6 cm in length by 2.3 cm in width by 0.3 cm in depth. The resident had an area to the right heel which measured 2.4 cm in length by 2.2 cm in width. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the weekly pressure ulcer assessment for Resident #57 dated 11/28/23 revealed the stage IV pressure ulcer to the resident's sacrum measured 2.2 cm in length by 1.8 cm in width by 0.2 cm in depth with no description of the wound. The wound to the resident's right heel measured 4.5 cm in length by 4.8 cm in width. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the weekly pressure ulcer assessment for Resident #57 dated 12/05/23 revealed the stage IV pressure ulcer to the resident's sacrum measured 2.1 cm in length by 1.7 cm in width by 0.1 cm in depth with no description of the wound. The right heel wound measured 6.0 cm in length by 5.2 cm in width. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the weekly pressure ulcer assessment for Resident #57 dated 12/19/23 revealed the stage IV pressure ulcer to the sacrum measured 2.3 cm in length by 1.4 cm in width by 0.2 cm in depth with no description of the wound. The right heel wound measured 4.2 cm in length by 4.3 cm in width by 0.4 cm in depth. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the weekly pressure ulcer assessment for Resident #57 dated 12/26/23 revealed the stage IV pressure ulcer to the sacrum measured 1.8 cm in length by 1.0 cm in width by 0.2 cm in depth with no description of the wound. The right heel wound measured 4.4 cm in length by 4.2 cm in width by 0.4 cm in depth. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the weekly pressure ulcer assessment for Resident #57 dated 01/02/24 revealed the stage IV pressure ulcer to the sacrum measured 3.4 cm in length by 1.6 cm in width by 0.3 cm in depth with no description of the wound. The right heel wound measured 4.5 cm in length by 4.3 cm in width by 0.4 cm in depth. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the weekly pressure ulcer assessment for Resident #57 dated 01/09/24 revealed the stage IV pressure ulcer to the sacrum measured 1.2 cm in length by 1.3 cm in width by 0.3 cm in depth with no description of the wound. The right heel wound measured 4.8 cm in length by 4.6 cm in width by 0.4 cm in depth. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the weekly pressure ulcer assessment for Resident #57 dated 01/16/24 revealed the stage IV pressure ulcer to the sacrum measured 1.8 cm in length by 0.6 cm in width by 0.2 cm in depth with no description of the wound. The right heel wound measured 3.6 cm in length by 3.4 cm in width by 0.4 cm in depth. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the Treatment Administration Record (TAR) for Resident #57 dated December 2023 revealed the physician ordered treatment to the stage IV pressure ulcer to the sacrum (cleanse wound to sacrum with soap and water and pat dry, apply calcium alginate and Alleyn border foam dressing and change once daily) was not signed off as completed on the following dates: 12/03/23, 12/07/23, 12/11/23 and 12/12/23. The physician ordered treatment to the stage IV pressure ulcer to the heel (cleanse wound to right heel with soap and water, pat dry, apply calcium alginate and cover with border gauze once daily) was not signed off as completed on 12/12/23, 12/13/23 and 12/27/23. Review of the monthly physician's orders for Resident #57 for January 2024 revealed orders dated 01/17/24 to cleanse the stage IV pressure wound to the sacrum with wound wash or normal saline (NS), apply calcium alginate with silver and cover with border gauze daily and to cleanse the stage IV pressure wound to right heel with wound wash or NS, and to apply calcium with silver and border gauze daily. Observation on 01/17/24 at 1:10 P.M. of wound care for Resident #57 per Licensed Practical Nurse (LPN) #190 and State tested Nursing Assistant (STNA) #219 revealed the staff completed the treatment to the pressure ulcers to the resident's sacrum and the resident's right heel. The resident had a dime-sized pressure ulcer to the sacrum which had visible necrotic tissue to the wound bed and a pressure ulcer to the right heel which was the size of a fifty-cent coin with visible slough to the wound bed. Interview on 01/18/24 at 8:25 A.M. with the Director of Nursing (DON) confirmed the facility staff did not conduct thorough wound assessments of Resident #57's stage IV pressure ulcer to the sacrum and the unstageable pressure ulcer to the right heel. The DON confirmed the facility measured the wounds weekly, but the assessments did not include a specific description of each wound and did not indicate whether or not the condition of the wound was improving or deteriorating and/or if the wound treatment needed to be changed. Further interview with the DON confirmed Resident #57 did not receive wound care as ordered to the right sacrum on 12/03/23, 12/07/23, 12/11/23 and 12/12/23 and did not receive wound care as ordered to the right heel on 12/12/23, 12/13/23 and 12/27/23. Review of the facility policy titled Wound Treatment Management dated 09/22/22 revealed wound treatments would be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing change. Review of the NPUAP guidelines dated 2014 at (https://npiap.com/general/custom.asp?page=2014Guidelines) pages 151 and 152 revealed pressure ulcers should be assessed initially and the re-assessed at least weekly. The nurse should document the results of all wound assessments. The assessment and documentation of the physical characteristics of the wound should include the following: location, category/stage, size, tissue type(s), color, peri wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, odor. The staff should use the findings of the pressure ulcer assessment to plan and document interventions that will best promote wound healing.

Based on medical record review, observation, and staff interview the facility failed to ensure accurate monitoring regarding resident consumption of physician ordered snacks. This affected one (Resident #54) of the three residents reviewed for nutrition. The facility census was 84. Findings include: Review of the medical record for Resident #54 revealed an admitted [DATE] with diagnoses including dementia, aphasia, psychosis, aphasia, vitamin B12 deficiency, and altered mental status. Review of the annual Minimum Data Set (MDS) assessment for Resident #54 dated 12/06/23 revealed the resident was cognitively impaired, was coded negative for significant weight loss, and received a mechanically altered diet. Review of the care plan for Resident #54 revised 01/12/24 revealed the resident was at risk for impaired nutritional status. Interventions included staff should provide snacks three times a day. Review of the physician orders for Resident #54 revealed an order dated 08/16/23 for the resident to receive three snacks a day. Review of the Medication Administration Record (MAR) for Resident #54 for January 2024 revealed on 01/16/24 the resident was documented as having consumed 100 percent of the morning snack and 100 percent of the lunch snack. On 01/17/24 Resident #54 was documented as having consumed 50 percent of morning snack and 100 percent of the lunch time snack. On 01/18/24 Resident #54 was documented as having consumed 50 percent of the morning snack. Review of the nutritional risk assessment for Resident #54 dated 12/12/23 revealed the resident received peanut butter sandwiches for snacks because they provided increased protein. Observation on 01/16/23 at 4:15 P.M. revealed Resident #54 was lying in bed sleeping. There was half of a peanut butter sandwich lying on the resident bedside table in plastic bag which had not been opened or consumed. The bag was labeled with the resident's name and a date of 01/16/24. Observation on 01/17/24 at 8:45 A.M. revealed Resident #54 was lying in bed sleeping. There was half of a peanut butter sandwich on the residents bedside table in a plastic bag which had not been opened. The bag was labeled with the resident's name and was dated 01/17/24. Interview on 01/17/24 at 8:51 A.M. with State tested Nursing Assistant (STNA) #126 confirmed the morning snack for Resident #54 was unopened and had not been consumed. STNA #126 stated Resident #54 frequently refused her snacks. Observation on 01/17/24 at 2:10 P.M. revealed Resident #54 was up ambulating in the room. There was half of a peanut butter sandwich on the residents bedside table in a plastic bag which had not been opened. The bag was labeled with the resident's name and was dated 01/17/24. Interview on 01/17/24 at 2:15 P.M with STNA #126 confirmed the snack for Resident #54 was unopened and had not been consumed. STNA #126 stated the resident had again refused the snack. Observation on 01/18/24 at 10:23 A.M. revealed Resident #54 was lying in bed sleeping. There was half of a peanut butter sandwich on the residents bedside table in a plastic bag which had not been opened. The bag was labeled with the resident's name and was dated 01/18/24. Interview 01/18/24 at 10:39 A.M. with STNA #126 confirmed the morning snack for Resident #54 was unopened and had not been consumed and the resident had refused the snack. STNA #126 further stated the nurse on duty documented the percentage of the residents' snacks consumed. Interview on 01/18/24 at 10:34 A.M with Dietary Supervisor (DS) #120 on 01/18/24 at 10:34 A.M. confirmed the kitchen provided Resident #54 with a snack of half of a peanut butter sandwich in the morning, at lunch time, and in the evening to fulfill the physician's order of a snack three times a day. Interview on 01/18/24 at 10:42 A.M. with Licensed Practical Nurse (LPN) #102 confirmed nurses documented the percentage of snacks consumed by residents in the MAR and relied on the STNAs to tell the nurses the percentage of the snacks consumed by the resident.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure oxygen saturation levels and respiratory rates were monitored as ordered by the physician for residents with impaired respiratory status. This affected one (Resident #21) of two residents reviewed for respiratory care. The facility census was 84. Findings include: Review of the medical record for Resident #21 revealed an admitted [DATE] with diagnoses including vascular dementia, shortness of breath, chronic obstructive pulmonary disease (COPD), and nicotine dependence. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #21 dated 10/20/23 revealed the resident was mildly cognitively impaired. Review of the care plan for Resident #21 dated 07/28/23 revealed the resident was at risk for impaired gas exchange related to shortness of breath and COPD. Interventions included monitor oxygen saturation as ordered and as needed. Review of the physician's orders for Resident #21 revealed an order dated 08/29/23 to obtain vital signs every Wednesday on night shift. Review of the vital sign records for Resident #21 from October 2023 to January 2024 revealed the last recorded oxygen saturation levels for the resident was done on 10/25/23 and the resident's record did not include any subsequent assessments of oxygen saturation. Review of the vital sign records for Resident #21 from November 2023 to January 2023 revealed the last documented respiration rate for the resident was done on 11/17/23 and the resident's record did not include any subsequent assessments of respiratory rates. Interview on 01/18/24 at 8:28 A.M. with Licensed Practical Nurse (LPN) #190 confirmed Resident #21 had a physician's order for vital signs to be obtained every week on Wednesday on night shift. LPN #190 further confirmed the last recorded oxygen saturation level for Resident #21 was done on 10/25/23 and the last recorded respiratory rate for Resident #21 was done on 11/17/23. Review of the facility policy titled Vital Signs undated revealed vital signs were indicators of health status and included temperature, pulse, respiratory rate, blood pressure, oxygen saturation level, and pain level. Licensed nurses were responsible for knowing the usual range of a resident's vital signs, analyzing and interpreting routine vital signs, and notifying the physician of abnormal findings.

Based on medical record review and staff interviews the facility failed to ensure residents with post-traumatic stress disorder (PTSD) were appropriately assessed with care plans implemented to minimize triggers and/or re-traumatization. This affected one (Resident #76) of two facility-identified residents with PTSD/history of trauma. The facility census was 84. Findings include: Review of the medical record for Resident #76 revealed an admitted [DATE] with diagnoses including PTSD, schizophrenia, bipolar disorder, and anxiety. Review of the admission Minimum Data Set (MDS) assessment for Resident #76 dated 11/07/23 revealed the resident was cognitively intact and was coded for an active and current diagnosis of PTSD. Review of the care plan for Resident #76 initiated 11/01/23 revealed the plan did not identify the cause of the resident's PTSD, triggers which could cause re-traumatization and/or interventions to reduce the risk of re-traumatization and provide care for PTSD symptoms. Interview on 01/22/24 at 9:20 A.M. with the Director of Nursing (DON) confirmed the facility had not conducted an assessment regarding the source of Resident #76's PTSD and the possible triggers which could cause re-traumatization for the resident. The DON further confirmed the facility had not implemented a care plan for Resident #76 to minimize the risk of re-traumatization and care for PTSD symptoms.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure residents were free of significant medication errors. This affected one (Resident (#54) out of the five residents reviewed for unnecessary medications. The facility census was 84. Findings include: Review of the medical record for Resident #54 revealed an admitted [DATE] with diagnoses including dementia, psychosis, and hypothyroidism. Review of the physician's orders for Resident #54 revealed an order dated 07/28/23 for 100 micrograms (mcg) of levothyroxine sodium (a thyroid hormone) once a day for hypothyroidism. Review of the laboratory results for Resident #54 dated 11/27/23 revealed the resident had a thyroid stimulating hormone (TSH) level of 0.139 milliunits per liter ([NAME]/L) which was a below normal result indicating the need for decreased thyroid hormone. The normal range was 0.4 to 4.0 [NAME]/L. Further review revealed Nurse Practitioner (NP) #500 reviewed the laboratory result on 11/29/23 and documented an order at the bottom of the page to decrease the dose of levothyroxine sodium for Resident #54 to 50 mcg per day and to recheck the resident's TSH level in eight weeks. Review of the physician's orders for Resident #54 revealed an order dated 11/29/23 to administer 50 mcg of levothyroxine sodium once a day for hypothyroidism. Review of the consultant pharmacist's Medication Regimen Review (MRR) recommendation for Resident #54 dated 12/05/23 revealed on 11/29/23 a new order for levothyroxine 50 mcg was added and the order for levothyroxine 100 mcg was still active. Further review revealed there were no progress notes or lab work related to the new order and it was unclear if the new order reflected an increased or decreased dose of levothyroxine. The Director of Nursing (DON) had written on the bottom of the MRR recommendation form that the time of administration had been updated. Review of the annual Minimum Data Set (MDS) assessment for Resident #54 dated 12/06/23 revealed the resident was cognitively impaired. Review of the December 2023 and January 2024 Medication Administration Records (MARs) for Resident #54 revealed the resident was administered a 100-mcg dose and a 50-mcg dose of levothyroxine sodium daily from 12/06/23 to 01/17/24 for a total of 150 mcg per day. Review of the TSH results for Resident #54 dated 01/19/24 revealed the resident had a low TSH level of 0.030 [NAME]/L. Interview with the DON on 01/22/24 at 9:05 A.M. confirmed Resident #54's TSH level on 11/27/23 was low. The DON confirmed NP #500 gave an order on 11/29/23 to decrease the dose of levothyroxine from 100 mcg per day to 50 mcg per day. The DON further confirmed the facility staff did not discontinue the 100-mcg dose of levothyroxine, and the nurses had administered 150 mcg per day of levothyroxine to Resident #54 rather than the reduced dose of 50 mcg per day ordered by NP #500. DON further confirmed this was a medication error identified by the surveyor. Interview with NP #500 on 01/22/24 at 10:49 A.M. confirmed she wrote an order on 11/29/23 to decrease Resident #54's levothyroxine sodium from 100 mcg per day to 50 mcg per because the resident's TSH level was low on 11/27/23 which indicated a need for a decreased dose of the medication. NP #500 confirmed the surveyor identified a medication error which resulted in the resident receiving an increased dose of levothyroxine sodium. NP #500 further confirmed the increased dose of levothyroxine could result in increased confusion and lethargy for the resident. Review of the facility policy titled Medication Errors dated 09/29/23 revealed significant medication errors included errors which caused the resident discomfort or jeopardized his/her safety. The facility should ensure residents were free from significant medication errors. This deficiency represents non-compliance investigated under Complaint Number OH00149963.

Based on medical record review and staff interview the facility failed to ensure physician visit notes were accurately documented in the resident medical record. This affected one (Resident #15) of 22 resident records sampled. The facility census was 84. Findings include: Record of the medical record for Resident #15 revealed an admitted [DATE] with diagnoses including bipolar disorder, dementia with behavioral disturbance, and history of falling. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #15 dated 12/20/23 revealed the resident had mildly impaired cognition. Review of the nurse progress notes for Resident #15 revealed the resident was sent to the emergency room and was admitted to hospital on 11/10/23. The resident was readmitted to the facility on [DATE]. Review of the physician progress note for Resident #15 dated 11/16/23 revealed the physician examined the resident in the facility for a 60-day regulatory visit. Interview on 01/18/24 at 8:00 A.M with the Director of Nursing (DON) confirmed Resident #15 was admitted to the hospital on 11/10/23 and did not return to the facility until 11/29/23. The DON further confirmed Physician #400 would not have been able to conduct a visit with Resident #15 in the facility on 11/16/23 as the resident was admitted to the hospital at that time. Telephone interview with Physician #400 on 01/22/24 at 4:00 P.M. confirmed the physician progress note for Resident #15 dated 11/16/23 had been documented in error. Physician #400 confirmed he had not examined the resident on that date.

Based on closed medical record review, staff interview, and facility policy review, the facility failed to timely notify the physician of a significant change in condition for one resident (Resident #109). This resulted in Immediate Jeopardy when Resident #109, who was recently hospitalized for [REDACTED]. A message was left for the physician with no return call and no additional attempts were made to contact the physician for approximately five hours. Actual harm occurred when Resident #109 was found without respirations. Cardiopulmonary resuscitation (CPR) was initiated and Resident #109 was pronounced dead at the hospital. This affected one of four residents reviewed for change in condition and death. The facility census was 108 residents. On [DATE] at 11:45 A.M., the Administrator and the Director of Nursing (DON) were notified that Immediate Jeopardy began on [DATE] at 1:00 A.M. when the facility failed to appropriately contact Physician #142 regarding a significant change in condition for Resident #109 that continued throughout the night, including pain; nausea and vomiting, cool, clammy, grey skin; change in continence; and increased respirations and pulse. Licensed Practical Nurse (LPN) #175 left a voice message for Physician #142 on [DATE] at 1:00 A.M. however, LPN #175 never spoke with the physician. No additional attempts were made to contact Physician #142. On [DATE] at 7:49 A.M., Resident #109 stopped breathing, CPR was initiated, she was transferred by EMS to the hospital and was pronounced dead. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 12:00 P.M., the Administrator and DON met with clinical management staff to discuss findings and develop a plan of action · On [DATE] at 12:30 P.M., the facility provided a revised Change in Condition Policy to include steps for physician notification, when to send residents to the emergency room for further evaluation and the addition of a review of the resident's clinical condition with a registered nurse (RN). · On [DATE] at 12:45 P.M., the facility provided a new Change in Condition Data Collection Tool which will be used for monitoring the nursing staff's response to resident changes in condition. This will be filled out by the nurse on duty and reviewed with an RN. · On [DATE] from 1:00 P.M. to 1:25 P.M., the DON in-serviced all RNs and LPNs currently in the facility regarding the Change in Condition Policy and Change in Condition collection tool. · On [DATE] at 1:30 P.M., the Assistant Director of Nursing (ADON) called unavailable RNs and LPNs between 1:30 P.M. and 1:50 P.M. to review the Change in Condition Policy and Change in Condition Collection Tool. Nursing staff that were not able to be reached by phone will be in-serviced prior to returning to work. · On [DATE] at 2:00 P.M., copies of all Change in Condition Data Collection Tool forms were observed placed at each nurse's station in a folder marked Change in Condition. · On [DATE] between 2:50 PM and 3:10 P.M., the DON in-serviced second shift oncoming RNs and LPNs regarding the Change in Condition Policy and the Change in Condition Data Collection Tool. · On [DATE], a quality assurance meeting attended by the Administrator, DON, and the Medical Director (Physician #142) was held to review the findings and discuss the plan of action. · On [DATE], the facility implemented the daily review of the 24-hour report and the Change in Condition Data Collection Tool. This will be completed by the DON or designee in the morning meeting. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Medical record review revealed Resident #109 had an original admission date of [DATE], and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) physician orders [REDACTED]. Review of advance directive information, dated [DATE], revealed the resident wanted life sustaining treatment. Review of a significant change Minimum Data Set 3.0 (MDS) assessment, dated [DATE], revealed Resident #109 had moderate cognitive deficits. The resident's speech was clear, she usually made herself understood, and she was able to understand others. Review of the medical record for Resident #109 revealed she had a recent hospital stay on [DATE] at which time she experienced left sided weakness, difficulty with ambulation and a slight droop to the right side of her mouth. Resident #109 was admitted to the hospital and a computed tomography (CT) scan showed an old left Post Cerebral Artery (PCA) infarct. Resident #109 was readmitted to the facility on [DATE]. Review of nurse's notes by LPN #175 dated [DATE] revealed Resident #109 remained continent of bowel and bladder, right sided facial drooping was unchanged, temperature ranged from 97XXX,[DATE].7 Fahrenheit (F), pulse ranged from ,[DATE], respirations were 16, and blood pressure ranged from ,[DATE]-,[DATE]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of a skilled nursing note from LPN #175 dated [DATE] at 1:00 A.M. with a lock time of 2:39 A.M. revealed Resident #109 was restless/fidgety/anxious; nausea and vomiting; incontinent of bowel with diarrhea; complaints of pain rated an 8 on a scale of 10 above the belly button. Tylenol was given and was effective. Oxygen saturation was 95 percent on room air; skin was pale, gray tinged, cold, clammy and the resident experienced chills. The note indicated respirations were 56 and shallow; pulse was 110; blood pressure was ,[DATE]; and temperature 95.6 F. The nurse's note indicated a message was left with Physician #142 and awaiting response. Review of nurse's notes written by LPN #175 on [DATE] at 5:17 A.M. revealed Resident #109's blood pressure was ,[DATE], pulse was 126, respirations were 54 and shallow, axillary temperature 95.3 and oxygen saturation was 95 percent. An axillary temperature was obtained due to facial drooping as the resident could not keep her mouth closed around the thermometer. The note indicated the resident denied any discomfort or chest pain. The note revealed No distress and will continue to monitor. Review of nurse's notes by LPN #176 dated [DATE] revealed at 7:40 A.M. State tested Nursing Assistant (STNA) #192 reported that Resident #109 was pale in color and had a small emesis. LPN #176 documented at 7:45 A.M. she noticed Resident #109's skin was pale, cool, and clammy; her fingernails were cyanotic; respirations 12; breaths labored; and she was unable to obtain an oxygen saturation level. LPN #176 yelled for LPN #175 to notify RN #110, the charge nurse for day shift on [DATE], of a change in condition of Resident #109 Review of nurse's notes from LPN #176 dated [DATE] at 7:49 A.M. revealed the she reentered Resident #109's room and the resident took three breaths (and ceased). CPR was initiated by LPN #176. Review of nurse's notes from RN #110 dated [DATE] at 7:59 A.M. revealed emergency medical services (EMS) was in the facility, applied a cardiac monitor, and CPR continued with ambu bagging and 15 liters per minute of oxygen. Review of nurse's notes by RN #110 dated [DATE] at 8:04 A.M., revealed Resident #109 left the facility with EMS and was taken to the emergency room . Review of nurse's notes by RN #110 dated [DATE] at 8:46 A.M. revealed a call was placed to the hospital and it was revealed that Resident #109's time of death was at 8:32 A.M. On [DATE] at 6:58 A.M., a telephone interview was conducted with LPN #175 who verified she was Resident #109's nurse on the night of [DATE]. She said she called Physician #142 and verified she left him a message that the resident was having a change in condition. LPN #175 said she never spoke with Physician #142 throughout the night, never tried to call him back, and that she monitored Resident #109 throughout the night. On [DATE] at 8:42 A.M., interview with the DON revealed she reviewed Resident #109's nurses notes, and she did not do any investigation as she did not see anything wrong with the events of that night leading up to Resident #109's death. She stated LPN #175 was one of their better nurses and if she felt she needed sent (to the hospital) she would have sent her out. The DON verified Physician #142 was also the facility medical director. On [DATE] at 9:30 A.M., interview with LPN #176 revealed she was the oncoming nurse on [DATE] at 7:00 A.M. She said she was told in report that Resident #109 was not feeling well and had an emesis right at shift change. LPN #176 stated if she was unable to contact Physician #142 and felt a resident needed sent to the hospital, she would send the resident per nursing judgment and notify the physician at a later time. LPN #176 said they also can text Physician #142 to contact him. LPN #176 stated she entered Resident #109's room at 7:45 A.M. and the resident's fingers were cyanotic, and respirations were 12. LPN #176 indicated she yelled out for LPN #175 to notify the charge nurse (RN #110) on duty. She stated she left the room to get her vital sign equipment and when she returned to Resident #109's room at 7:49 A.M., the resident took three breaths and she initiated CPR while the charge nurse (RN #110) called 911. On [DATE] at 9:45 A.M., interview with RN #110 revealed she was the unit manager on [DATE] for day shift and that she had called 911 for Resident #109. RN #110 stated Certified Nurse Practitioner (CNP) #215 was in the facility to do rounds and assisted with CPR until EMS arrived. On [DATE] at 1:33 P.M., telephone interview with Physician #142 revealed he has three telephone numbers (home, cellular, and pager) that were provided to the facility to contact him, and that it was very rare that he could not be reached. He said he would expect the nurses to use nursing judgment to send a resident out to the hospital if he could not be reached. Physician #142 said he could not state if what the LPN #175 did the night of [DATE] for Resident #109 was right or wrong, but the nurse should use nursing judgement. A telephone interview was conducted on [DATE] at 9:41 A.M. with LPN #175, who verified that she called Physician #142 after the first assessment of Resident #109 on [DATE] at 1:00 A.M., which she later documented in the medical record at 2:39 A.M. On [DATE] at 4:00 P.M. observation was conducted with ADON #104 of all three nurse's stations in the facility and revealed each station contained a file folder that included the new Change in Resident's Condition or Status Policy and Procedure and the new Change in Condition Data Collection Tool forms. On [DATE], an interview was conducted at 4:05 P.M. with LPN #113. She stated she received a phone call from the DON on the new Change in Condition Policy and Change in Condition data collection tool on [DATE] and was also shown the documents on [DATE] before working the floor. Additional interviews between 4:07 P.M. and 4:10 P.M. with LPN #117, LPN #178 and LPN #177 revealed they were knowledgeable of the new Change in Condition Policy and tool to be used. Review of the facility Change in Resident's Condition or Status Policy and Procedure (dated (MONTH) (YEAR)) revealed the facility shall promptly notify the resident, attending physician, and representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call including when there has been a significant change in condition and need to transfer the resident to a hospital. This deficiency substantiates Complaint Number OH 909.

Based on closed record review, staff interview, and review of a facility in-service report the facility failed to ensure ventilator settings were according to physician orders [REDACTED].#157). This resulted in Immediate Jeopardy when the apnea alarm was not turned on for Resident #157 to alert staff to the resident not initiating spontaneous breaths. Actual harm occurred when Resident #157 was found unresponsive, without pulse or respirations. This affected one of two sampled residents reviewed that were ventilator dependent. The facility identified seven residents on ventilator support. The facility census was 108 residents. On 09/27/18 at 11:45 A.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on 08/25/18 at 12:05 A.M. when Resident #157's apnea monitor was not set to alarm, and the resident was found unresponsive. On 08/25/18 at 12:05 P.M. Resident #157 was found unresponsive by Licensed Practical Nurse (LPN) #112. LPN #112 stated the apnea alarm did sound on 08/25/18 when Resident #157 was found. LPN #112 summoned Registered Nurse (RN) #110 who reported Resident #157 was without pulse and respirations. The DON stated the alarm was turned off because it kept sounding. The Immediate Jeopardy was removed on 09/27/18 when the facility implemented the following corrective actions: · On 09/27/18 at 12:00 P.M. the Administrator and DON met with the clinical management staff to discuss the findings and develop a plan of action. · On 09/27/18 at 12:30 P.M. nursing management developed an audit sheet and conducted audits of all ventilator settings and physician orders [REDACTED]. · On 09/27/18 at 12:40 P.M. the Administrator developed Respiratory Therapy Vent Flow Sheet-2nd check form. The DON developed a vent policy for switching between modes or changing vent settings. · On 09/27/18 at 1:00 P.M. from 1:00 P.M. to 1:25 P.M. the DON conducted an in-service for three RN's, three LPN's, and one Respiratory Therapist (RT) currently in the facility regarding the policy on switching between modes or changing vent setting and the Respiratory Therapy Vent Flow Sheet-2nd check form. · On 09/27/18 At 1:30 P.M. the Assistant DONs placed calls between 1:30 P.M. and 1:40 P.M. to three RN's, 10 LPN's, and five RT's that were not working to review the policy changes and review the vent 2nd check form. All RN's, LPN's, and RT's that were unavailable via phone will be in-serviced before returning to work. · On 09/27/18 at 2:00 P.M. the DON placed Respiratory Therapy Vent Flow Sheet-2nd check form in the Respiratory room and at the front desk in a folder labeled vent -2 person checks. · On 09/27/18 at 3:00 P.M. the DON in-serviced second shift on-coming one RN and three LPN's between 2:50 P.M. and 3:10 P.M. regarding the policy on switching between modes or changing vent setting and the Respiratory Therapy Vent Flow Sheet-2nd check form. · The DON or designee will audit the vent settings and compare to the physician orders [REDACTED]. · On 09/27/18 at 6:15 P.M. a telephone conference was held with the Medical Director, Administrator, and DON. The Medical Director agreed with the above changes made. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (No actual harm with potential for minimal harm that is not Immediate Jeopardy) as the facility is still in the progress of implementing their corrective action plan to ensure on-going compliance. Findings include: Record review revealed Resident #157 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #157's Minimum Data Set 3.0 (MDS) assessment, dated 08/16/18, revealed speech was unclear, rarely/never made herself understood or understood others, and had severely impaired decision making. Resident #157 had no behavior problems and did not reject care. Resident #157 was dependent on two or more staff for bed mobility, transfer, dressing eating, toilet use, and had no functional impairment of range of motion. Resident #157 received [MEDICAL TREATMENT], oxygen, suctioning, had a [MEDICAL CONDITION], and was on a ventilator. Review of Resident #157's physician's orders [REDACTED]. In this mode the apnea alarm would sound to alert staff the resident was not taking breaths after 20 seconds. Ventilator settings at night were assist control (AC) respiratory rate (RR) 12 tidal volume (VT) 450 positive end expiratory pressure (PEEP) 5, oxygen at five liters per minute. Resident #157 had a do not resuscitate comfort care arrest (DNRCC-A) order. Review of Resident #157's plan of care, dated 08/14/18, revealed Resident #157 was at risk for impaired gas exchange related to [MEDICAL CONDITION] with [MEDICAL CONDITION]/ventilator. The goal was for the resident to have no signs or symptoms of respiratory distress through review date (11/12/18). The interventions were to assess lung sounds as needed, elevate the head of the bed to prevent shortness of breath while lying flat, circuit (the ventilator tubing and any other devices connected to it) as ordered, suction every shift and record number of times, [MEDICAL CONDITION] care twice daily and as needed, Trilogy electric vent with battery/generator back up power. Vent weaning as tolerated S mode, IPAP12, EPAP 6, oxygen at five liters per minute, apnea alarm within 20 seconds. Continuous pulse oximeter during weaning. Ventilator settings at night; AC, RR 12, VT 450, PEEP 5, oxygen at five liters per minute. Review of Resident #157's progress notes, authored by RT #202, on 08/20/18 at 6:05 P.M. revealed the resident was beginning to tire on the S mode, her peripheral oxygen levels were dropping to 90% and she was switched to the AC mode. On 08/23/18 at 1:30 P.M. the progress note authored by RN #109 revealed Resident #157's pulse ox was alarming, and her oxygen saturation was 64% on continuous positive air pressure ([MEDICAL CONDITION]) mode. Her oxygen was increased to seven liters per minute, she was suctioned, the head of the bed was elevated, and the oxygen saturation rate increased to 85%. Resident #157's ventilator was switched to AC mode to help with labored respirations and to increase oxygen saturations. Within one-minute Resident #157's oxygen saturation level was greater than 90% and her oxygen was decreased to five liters per minute. Review of Resident #157's progress notes from 08/20/18 to 08/25/18 did not reveal the apnea alarm was sounding frequently. Review of the respiratory therapy vent flow sheets for Resident #157 revealed the apnea alarm settings were documented as 20 on 08/20/18 at 9:00 A.M., 12:30 P.M., 4:40 P.M., 08/21/18 11:00 A.M., 12:20 P.M., 08/22/18 8:05 A.M., 12:45 P.M., 4:20 P.M., and 7:41 P.M. The medical record provided no evidence the apnea alarm was functioning after 08/22/18. Review of Resident #157's progress notes revealed she returned on 08/25/18 at 10:01 A.M. from the [MEDICAL TREATMENT] center on the ventilator with oxygen via ventilator as ordered. Respirations were easy and even. Resident #157 was transferred by LPN #118 and a State tested Nurse Aide (STNA) to bed. On 08/25/18 at 12:05 P.M. RN #110 was summoned to Resident #157's room by LPN #112 who had found the resident without respirations. Resident #157 had no spontaneous respirations, no apical pulse, no carotid pulse, no brachial pulse, no blood pressure, and there was no oxygen saturation percentage or heart rate on the pulse oximeter (pulse ox). The resident's pupils were fixed, and she was nonresponsive. Interview with RN #110 on 09/26/18 at 3:00 P.M. revealed the ventilator was not alarming, but it was working, and Resident #157 was not breathing. Interview with Respiratory Therapist (RT) #199 on 09/26/18 at 3:25 P.M. revealed if the 20 second apnea alarm was set, and the resident did not breath on her own after 20 seconds, the alarm should sound to let staff know the resident was not breathing. Interview with LPN #112 on 09/27/18 at 8:50 A.M. revealed on 08/25/18 Resident #157's pulse ox was alarming. Resident #157 had no pulse and no oxygen saturation. LPN #112 moved the pulse ox to another finger and there was still no pulse or oxygen saturation. LPN #112 turned the pulse ox off to check the resident. LPN #112 indicated there were other alarms on the ventilator, but they were not alarming. Interview with the DON on 09/27/18 at 9:53 A.M. revealed they used the pulse ox for Resident #157 and not the apnea alarm. The DON stated the apnea alarm was constantly sounding for Resident #157 because she took such shallow breaths. The DON revealed the facility did not have a policy to check the ventilator settings. Interview with RT #199 on 09/27/18 at 10:20 A.M. revealed the ventilator had two settings the AC and S modes. He stated both modes were programmable into the machine and could be switch from one mode to another without manually disrupting any settings. Observation of the ventilator with RT #199 revealed to access the alarm setting staff had to enter under alarm/settings and scroll down to turn the alarm off or on. RT #199 stated any resident who was receiving ventilation via S Mode should have the apnea monitor turned on. When the resident was on the AC Mode it was not necessary for the apnea monitor to be on. RT #199 stated apnea monitoring and pulse oximeter monitoring was not the same due to pulse ox was a measurement of the oxygen in the red blood cell and apnea noted the lack of someone breathing. RT #199 stated he would not turn any apnea alarm off, even if alarming sounded frequently. Interview with Certified Nurse Practitioner (CNP) #215 on 09/27/18 at 10:37 A.M. revealed the pulse ox was more sensitive and she felt comfortable with the pulse ox in place of the apnea alarm. CNP #215 stated it would be a standard of care to use the pulse ox. Interview with CNP #215 on 09/27/18 at 11:16 A.M. revealed it did not matter that the resident was dependent on a ventilator, the pulse ox was more sensitive than the apnea monitoring. The apnea monitoring had a lot of false positives that take time away from other residents as well as leading to alarm fatigue in staff. Interview with LPN #112 on 09/27/18 at 11:29 A.M. revealed she did not remember Resident #157's pulse ox setting. LPN #112 stated the RT usually turns on and off alarms, nurses usually hit reset, but are able turn off the alarm. Interviews on 09/28/18 between 2:50 P.M. and 3:15 P.M. of RN #112, RT #145, and LPN #113 revealed they were knowledgeable of the two staff check and monitoring for residents on ventilators. Interview of LPN #111 on 09/30/18 at 2:36 P.M. revealed she was knowledgeable of the two staff check and monitoring for residents on ventilators. Interview of RT #199 on 10/02/18 at 12:30 P.M. revealed he was knowledgeable of the two staff check and monitoring for residents on ventilators. This deficiency substantiates Complaint Number OH 909.

Based on medical record review, facility policies related to Infection control and pressure ulcers and staff interview the facility failed to provide necessary care and services to prevent the development of a stage III pressure ulcer, failed to provide wound management care timely and prevent infection resulting in hospitalization , surgery and failed to recognize the signs and symptoms [MEDICAL CONDITION] causing harm to one of three residents, #201, reviewed for pressure sores. The harm occurred when the facility failed to provide treatment to a stage III pressure are which resulted in an infection and a surgical debridement. Findings include: Resident #201 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident received oxygen per tracheotomy mask. The "minimum data set" assessment completed 6/19/13 revealed the resident was reliable for interview, had a urinary catheter in place, required extensive assist of two for bed mobility, was non-ambulatory, an extensive assist for dressing, limited assist for eating, extensive assist of two for toileting and extensive assist of one for personal hygiene. The resident weighed 321 pounds and was 69 inches tall. The resident was occasionally incontinent of bladder, (Foley catheter removed), and always continent of bowel. The document indicated the resident had no pressure ulcers present but documented moisture associated skin damage. A nurses note on 5/31/13 at 9:00 P.M. indicated the resident refused to be turned two times but did allow the staff to position her to the side with a positional device. The resident was out of the facility on 6/4/13 for facial drooping and increased lethargy. The resident returned to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nursing assessment completed upon return from the hospital admission revealed a red excoriated area on the coccyx that was blanchable. The resident had a urinary catheter in place. Review of the physician's progress note on 6/19/13 revealed the removal of the urinary catheter. The physician's orders [REDACTED]. This order was documented as given on 5/31/13 by the physician on admission and resumed upon return on 6/13/13. The areas were identified as avoidable. Review of the plan of care for Resident #201 initiated on 6/13/13 revealed the resident was identified as at risk for skin breakdown due to impaired bed mobility, [MEDICAL CONDITION], incontinence, diabetes mellitus, [MEDICAL CONDITION], cronic obstructive [MEDICAL CONDITION] disorder, [MEDICAL CONDITION]. The plan of care indicated the resident refused to turn and removed pillow from back when positioned. The goal was to have no avoidable skin breakdown. The interventions included apply moisture barrier to peri area after each incontinence, a pressure reducing low loss air mattress to the bed and a cushion to the chair. The plan of care indicated the resident required two persons to assist to turn and reposition every two hours. The resident was to receive education about risk/benefit of turning and repositioning as needed. Observe skin for red or open areas every shift. Report to nurse if noted. Treat right buttocks and coccyx maceration with a moisture barrier cream per order and assess weekly. Review of the treatment record and treatment progress notes for Resident #201 revealed documented coccyx abrasion with 4 centimeter (cm) round red area without an open area. The area on the right buttocks was noted as an abrasion 6 cm x 2 cm red area without an open area. Documentation on 6/20/13 noted the coccyx abrasion was a 4 cm round red without an open area and an abrasion 6 cm x 2 cm. area red and without an open area to the right buttocks. The treatment record revealed the treatment to the areas was to cleanse coccyx abrasion and the right buttock abrasion with soap and water and apply triad paste (moisture barrier) every shift and as needed. The treatment for [REDACTED]. On 6/24/13 it was discontinued when both areas were documented as an open area and referred to as moisture associated skin damage, (MASD). The order was changed to [MEDICATION NAME] cream (used for diaper rash) after each incontinence. Review of the treatment progress notes revealed on 6/24/13 the area on the right buttocks measured 5 cm. by 5 cm. by 0.1 cm. deep. The area on the coccyx was measured 2.5 cm. by 0.2 cm and 0.1 cm. deep. The medical record for Resident #201 documentation on 6/27/13 on the treatment progress note revealed the open area on the right buttocks measured 5 cm. by 5 cm. by 0.2 cm. and the open area on the coccyx measured 2.5 cm by 2 cm. by 0.2 cm. deep. The facility continued to identify the areas as MASD. There was no change in treatment to the two areas and no change in the plan of care. Further review of the medical record for Resident #201 revealed the treatment was discontinued on 7/10/13 when the resident was documented to have a stage III pressure ulcer on the sacrum which measured 3 cm. by 2 cm. and 0.3 cm. deep. The physician was notified and an order was received to cleanse the ulcer to the sacrum with wound cleanser and apply [MEDICATION NAME] dressing and change the dressing every 3 days. The treatment was documented as completed as ordered. The order continued to use [MEDICATION NAME] cream on the right buttocks area identified as MASD every shift and after each incontinence. A urinary catheter was ordered and inserted on 7/10/13. Documentation on 7/10/13 revealed the resident eats only 23% of meal but the family brings food in for the resident. The resident agreed to change to whole milk and 8 ounces of supper juice with meals to assist with the resident weight loss and skin condition. The note documented the resident refuses to turn. The resident was on a low air loss mattress for pressure relief. The medical record for Resident #201 documentation on the treatment progress record on 7/18/13 revealed the sacrum pressure wound measured 3 cm by 2 cm. and 1.5 cm. deep with the color red and yellow tissue with a small amount of drainage. Review of the nursing documentation on 7/18/13 revealed the physician was aware of wound measurements and description with no change in treatment orders. The medical record for Resident #201 documentation on the wound record on 7/24/13 revealed the wound progressed to an unstageable pressure ulcer due to slough in the wound bed. The physician was notified and a new treatment was started. Meal intake for Resident #201 increased to 71%. The note documented the resident was more compliant with turning. The measurements for the sacrum unstageable decubitus was 2 cm by 1 cm with slough tissue at greater then 76% of the wound. The treatment record initiated on 7/24/13 revealed the order was to cleanse the ulcer to the sacrum with wound cleanser and apply nickel thick santyl to ulcer wound bed, place a moistened 2 inch by 2 inch gauze to cover the area and place an ABD over the unstageable pressure ulcer and secure with tape. Complete the dressing change two times a day. Review of the nurse's notes for Resident #201 revealed on 7/27/13 at 1:30 P.M. revealed the dressing to the sacrum had to be changed due to the dressing was soiled. The resident complained of pain to her tail bone. The note included the resident refused to turn side to side. A note on 7/28/13 revealed the physician was made aware the resident was refusing to turn side to side, no new orders were given. There was no change in the resident plan of care. The physician was not notified of the resident complaint of pain to the tail bone. 7/28/13 resident requested [MEDICATION NAME] for nausea at 10:00 A.M. and was given as requested. A note on 7/28/13 11:15 A.M. revealed the resident had a large emesis of undigested medication, [MEDICATION NAME] was ineffective. The resident declined [MEDICATION NAME] due to vomiting. A review of the nurses note on 7/28/13 at 1:35 P.M. the resident had a large emesis of liquid at 1:30 P.M. The resident complained of stomach hurting and sick at her stomach. The note indicated the physician to be notified. The note on 7/28/13 at 4:00 P.M. revealed a new order for [MEDICATION NAME] suppository 25 milligram rectally every four hours as needed for nausea and vomiting after [MEDICATION NAME] when [MEDICATION NAME] was ineffective. A note at 4:45 P.M. a [MEDICATION NAME] suppository was given after [MEDICATION NAME] given was ineffective. Review of a note completed on 7/28/13 at 8:00 P.M. indicated physician was aware of the resident refusal of medication due to nausea and vomiting and an order was received for a complete blood count in the AM and complete metabolic profile. A note on 7/29/13 at 1:50 A.M. documented resident having dry heaves with a small emesis of clear mucus like liquid at the beginning of the shift. A review of documentation on 7/29/13 at 4:30 A.M. revealed the resident had emesis two times of dark green liquid. A review of documentation on 7/29/13 at 2:46 P.M. an assessment was completed on Resident #201 which revealed a blood pressure of 150/80 a pulse of 109, respirations of 18 and a Temperature of 99.2 degrees. The resident complained of abdominal pain and nausea and vomiting, the resident was described as pale. There was no notification of the physician documented of increased temperature, vomiting, for the past 24 hours with abdominal pain and appeared pale. On 7/29/13 at 6:40 P.M. an order was received to send the resident to the emergency room due to white count of 17.8, vomiting green with green mucus around the [MEDICAL CONDITION], abdominal pain with a blood pressure of 90/50, heart rate of 60 and a temperature of 99 degrees. Review of the emergency room report For Resident completed upon arrival on 7/29/13 revealed the resident was sent to the emergency room after green colored vomiting going on for the last three days. Upon arrival to the emergency room the patient was noted to have systolic pressures of 75 and 50. The resident had a temperature of 99.1 and a heart rate of 94. The resident was admitted to the intensive care unit. The resident's blood pressure is improving significantly with intravenous hydration. Review of the hospital report for Resident #201 completed on 7/29/13 admission history revealed the resident presented with [MEDICAL CONDITION], nausea and vomiting. The resident was admitted for a septic workup. The note indicated the nursing staff on the floor found the resident to have a draining coccygeal pressure ulcer. The document noted the pressure ulcer was foul smelling with drainage and undermining. The report documented the resident complained of pain with palpation of the area. Upon exam by the physician the pressure ulcer was documented as 3 centimeters wound of the coccyx with expressible thin, turbid foul smelling drainage with surrounding hyperemia with chronic pressure with no streaking or lymphangites. The report noted approximately 6 centimeters of tracking inferiorly, toward the right ischium. Resident #201 required a surgical debridement on 8/2/13 due to an infected coccygeal pressure ulcer for debridement of skin and subcutaneous tissue of the pressure ulcer. The excision debridement totaled the removal of 12 cm by 6 cm area due to a foul smelling necrotic coccygeal pressure ulcer. The surgical report indicated the pressure ulcer was 2 cm by 3 cm open area with adjacent to the coccyx that tracked caudally to the right ischium. The wound was then opened along it length to provide access to an underlying foul smelling pressure ulcer with necrotic tissue. The grossly necrotic tissue was excised. A review of the physician's progress note for Resident #201 after return to the facility on [DATE] was completed. The primary physician progress notes [REDACTED]. Review of the facility Infection Control Policy (no date), Revealed the primary purpose of the Manor's Infection Control plan is to establish guidelines to follow in preventing controlling and eliminating the spread of contagious infections or communicable diseases. The goal of the policy is to decrease the risk of infection to residents and personnel. The facility will monitor for occurrence of infection and implement appropriate control measures. The facility will identify and correct problems relating to infection control practices. The facility policy will use standard precautions and other barriers, provide appropriate treatment and follow-up. Review of the facility Pressure Ulcer Policy dated 08/09 revealed a resident who enters the Manor without a pressure ulcer will not develop a pressure ulcer unless the individual's clinical condition demonstrates they are unavoidable. All residents will be assessed for pressure ulcer risk. Appropriate preventative interventions will be implemented. the definition of pressure is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. A resident with a pressure ulcer will receive interventions and monitoring to promote healing, prevent infection and prevent new ulcers from developing. All residents will be placed on a pressure reducing mattress upon entering the Manor and no photographs of pressure ulcers will be obtained by the Manner. An observation of Resident #201 on 8/15/13 and 8/16/13 was not completed due to the resident was readmitted to the hospital again on 8/13/13. The last entry on the wound documentation indicated the sacral ulcer measured 7 cm. by 7 cm. and 6 cm. deep, stage IV with tunneling 2 cm. at 9 o'clock, 1 cm. at 12 to 3 o'clock. The wound documentation on 8/13/13 indicated the resident had a large amount emesis. A order change was made due to 10% slough upper portion of ulcer, redness surrounding the wound. Resident will only lay on left side. Resident readmitted back to hospital. A alternate physician note completed on 8/13/13 documented resident has fever, nausea, unable to take medications or nutrition and abdominal pain, order given to send to the emergency room . Review of the information concerning Resident #201 was completed with the Director of Nursing (DON) on 8/16/13 at 1:20 P.M. The DON stated the open area on the coccyx was classified as Moisture associated skin damage related to incontinence by Portsmouth hospital wound staff. The DON stated the resident would not eat and refused to reposition. This deficiency substantiates Complaint Number OH 404.

Based on clinical record review, facility policy review and staff interview, the facility failed to ensure one of four residents reviewed for accidents were provided adequate supervision to prevent accidents (Resident #165). The facility census was 160. Findings include: Harm occurred when Resident #165 who was assessed as requiring assistance of two staff for ambulation, was walking independently, fell and required sutures. Review of Resident #165's clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #165 was assessed as being at high risk for falls and had falls on 01/08/12, 05/15/12 and 06/23/12. Review of Resident #165's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had short and long term memory problems. Resident #165's functional status for activities of daily living (ADL) were assessed as the resident requiring extensive physical assistance of two persons for bed mobility, transfers, walking in room and in corridor, dressing and toilet use. The resident was assessed as requiring extensive one person physical assistance for eating and personal hygiene. The MDS identified the active [DIAGNOSES REDACTED]. Review of Resident #165's ADL care plan dated 06/19/12 revealed interventions directed two person assistance for transfers and one person assistance for ambulation. Review of Resident #165's resident care sheet dated 06/19/12 revealed the resident was a one person limited assistance for ambulation and was a fall risk. Review of Resident #165's at risk for falls care plan (updated 06/23/12) revealed interventions which included to apply slipper socks before getting up, keep call light within reach, respond to needs promptly, keep environment free of obstacles, do not leave unattended in the shower, keep bed in the lowest lockable position and when observed and assist as needed when navigating obstacles. Review of Resident #165's nursing notes dated 06/23/12 revealed the resident was in the small television lounge on the G Wing. Resident #165 was observed on the floor with a 4 centimeter (cm) laceration above the right eye, an observed abrasion below the right eye and upon completing the head-to-toe assessment another small abrasion to left knee was noted. The resident was confused and verbally stated "that hurts". Resident #165 was sent to the emergency room (ER). Review of Resident #165's transfer form dated 06/23/12 revealed the resident was being transferred to the ER for a fall with a laceration to the right eye brow. The documentation revealed the resident was ambulating, fell , struck her head causing lacerations to right eye brow with no loss of consciousness and no vomiting or nausea. The resident had Alzheimer's dementia. Review of Resident #165's physicians' orders dated 06/23/12 revealed an order to send the resident to the ER for evaluation of a right eyebrow laceration. On 06/23/12, the resident returned from the ER with new orders to keep the wound clean and dry, and remove the stitches in 10 days. Review of the facility's fall investigation for Resident #165 dated 06/23/12 revealed the resident was observed on the floor in television lounge at 7:30 A.M. There were no staff witnesses and the resident was unable to say what happened due to her dementia. The resident was sitting on a couch in the room and stated " she tripped over my feet ". The resident was assessed as being at high risk for falls. Interventions in place were non-skid socks; call light in reach and the resident was currently receiving physical therapy. Staff were interviewed and revealed at 7:20 A.M., the resident was provided with ADL care. The resident was walking around with a steady gait with no agitation. Resident #165 left the dining area at 7:28 A.M. and went across the hall into the television room at 7:30 A.M. The State tested nurse aide (STNA) in the dining room heard the resident fall in the quiet room. The resident ambulated well the majority of the time and only required more assistance from staff when agitated and resisting. The resident would continue therapy and the new intervention would be to assist her when navigating obstacles. Interview on 08/03/12 at 2:00 P.M. with the Director of Nursing (DON) reveled the resident only required extensive two person assist as the maximum amount of assistance required. The DON verified Resident #165's care plan stated the resident required assistance of one person and the reason it was different from the MDS was because the amount of assistance the resident required changed daily. The DON stated they determined daily the amount of assistance a resident required was based on how that resident was doing each day and the STNA could determine the need when they got the residents up in the morning or while they were walking them during the day. The DON stated the nurses' did not assess the residents needs each day regarding the amount of assistance they required. The staff including the STNA 's would base the decision on how the resident was doing each day. The DON verified Resident #165 was sent to the ER for a laceration above her right eye and received stitches. but stated she was having difficulty finding information from the hospital visit. Interview on 08/03/12 at 2:25 P.M. with STNA #20 revealed Resident #165 required assistance of one person to walk down the hall. STNA #20 stated the resident could walk down the hall by herself but she was at risk for falls and the staff must use the care plans. STNA #20 stated they have to okay any change in assistance for a resident from the care plan, then a nurse came and assessed the resident. STNA #20 stated the STNA's were not allowed to make the decision on whether or not a resident was assisted for ADL's and how much assistance they required, they had to base the amount of assistance from what the care plan stated. Interview on 08/03/12 at 2:30 P.M. with STNA #17 revealed Resident #165 required assistance of one person for ambulating. STNA #17 stated the resident was a fall risk and would tend to lean to the side while ambulating. STNA #17 stated the STNA's had to follow the care plans for resident care. STNA #17 stated she was working on the unit the day of the Resdient #165's fall. STNA #17 stated the resident had been up walking into the lounge because she had gotten up from her chair. STNA #17 verified she was not assisting the resident in ambulating and she did not see the resident fall but did heard her fall. Review of the facility's fall policy (dated April 2001) revealed the objective of the policy was to assess any resultant injuries sustained in a fall and provide necessary treatment. The procedure included not to leave the resident and call for help, check for injuries and if the condition warranted further treatment, notify the physician immediately or if no injury, notify physician of incident. Review of the facility's fall policy (dated April 2001) revealed the objective of the policy was to assess any resultant injuries sustained in a fall and provide necessary treatment. The procedure included not to leave the resident and call for help, check for injuries and if the condition warranted further treatment, notify the physician immediately or if no injury, notify physician of incident.