Every finding on record at The Pines Healthcare Center

Based on interviews and record reviews, the facility failed to obtain informed consent prior to the administration of psychotropic medications for two Residents (#22 and #73) of five residents reviewed for unnecessary medications. The facility census was 77.Findings include:1. A review of Resident #22's medical record revealed an admission date of 04/30/24 and pertinent diagnoses of chronic pain, depression, anxiety and cellulitis. Pertinent orders included Sertraline HCl Oral Tablet 50 milligrams (MG) (an antidepressant that belongs to a group of drugs called selective serotonin reuptake inhibitors (SSRIs), which works by balancing serotonin levels in the brain and nerves), Give 1 tablet by mouth in the morning for depression. This medication was ordered on 11/08/24. Another pertinent order was for Trazodone HCl Tablet 50 MG (a serotonin receptor antagonist and reuptake inhibitor ([NAME]), which means it helps restore the balance of serotonin, a neurotransmitter that regulates mood, sleep, and mental balance, in the brain), Give 1 tablet by mouth at bedtime for insomnia sleep disturbance. This medication was ordered on 09/05/25.Further review of Resident #22's medical record revealed no record of informed consents that included education, risks, benefits, and side effects of psychotropic medication use.A review of Resident 22's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Basic Interview of Mental Status (BIMS) score of 14 which indicated intact cognition, and revealed the resident required supervision with toileting, partial assistance with bathing, supervision with dressing, substantial assistance with personal hygiene, supervision with bed mobility, transfers and ambulation. A review or Resident #22's most recent care plan dated 02/27/26 revealed he used and was prescribed antidepressant medications with interventions that included educating the resident, resident representative of risks, benefits, and side effects of psychotropic medication use.An interview with the Director of Nursing (DON) on 05/14/26 at 2:30 P.M. revealed Resident #22 was provided with education, risks, benefits, and side effects of psychotropic medication use on 05/13/26 and a copy of the consent was provided at that time.4. A review of Resident #73's medical record revealed an admission date of 03/21/24 and pertinent diagnoses of depression and anxiety. Pertinent orders included Sertraline HCl Tablet, give 75 milligrams by mouth one time a day for Depression; this medication was ordered 06/21/25. Another pertinent order included Trazodone HCl Tablet 50 MG Give 1 tablet by mouth at bedtime for insomnia sleep disturbance; this medication was ordered 04/18/26. Another pertinent order was for Alprazolam Oral Tablet 0.25 MG (a benzodiazepine, group of medicines called central nervous system (CNS) depressants, which are medicines that slow down the nervous system) Give 1 tablet by mouth every morning and at bedtime for anxiety; this medication was ordered 04/27/26.Further review of Resident #73's medical record revealed no record of informed consents that included education, risks, benefits, and side effects of psychotropic medication use.A review of Resident #73's MDS 3.0 assessment dated [DATE] revealed a BIMS score of 15, which indicated intact cognition. Review of the MDS further indicated Resident #73 was independent with activities of daily living (ADL) except for needing substantial assistance with dressing, and she required supervision with bed mobility and transfers.A review of Resident #73's most recent care plan dated 03/26/26 revealed she used and was prescribed anti-anxiety and anti-depressant medication due to depression and anxiety. Interventions included she would be educated of risks, benefits, and side effects of psychotropic medication use.An interview with the DON)on 05/14/26 at 2:30 P.M. revealed Resident #73 was provided with education, risks, benefits, and side effects of psychotropic medication use on 05/13/26 and a copy of the consent was provided at that time.

Based on record reviews and interviews, the facility failed to develop comprehensive care plans Residents #4 and #85. This affected two residents (#4 and #85) of two residents who were investigated for comprehensive care plans. The facility census was 77.Findings include:1. A review of Resident #4's medical record revealed an admission date of 04/27/26 and a discharge date of 05/06/26. Resident #4's pertinent diagnoses included malignant neoplasm of parotid gland, sciatica, encounter for other plastic and reconstructive surgery following medical procedure or healed injury, peripheral vascular disease (PVD), hypertensive heart disease, hearing loss, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, hypothyroidism, delirium due to known physiological condition.A review of Resident #4's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS also revealed Resident #4 required substantial/maximum assistance with all activities of daily living (ADL) and partial assistance with bed mobility and transfers.A nursing note written on 05/06/26 at 10:40 A.M. revealed Resident #4 discharged per nurse practitioner (NP) order. The nurse reviewed the discharge summary and orders with Resident #4's son, and the son had no questions or concerns. The resident exited the facility via wheelchair accompanied by a transportation company and family. The resident exited the facility with all belongings and without injury.A review of Resident #4's comprehensive care plan showed no evidence of the resident 's preference for discharge planning or resources that were needed to support her plans to return safely to the community.On 05/14/26 at 11:04 A.M. an interview with Social Services Designee (SSD) #515 revealed she was not responsible for any part of the care plan.On 05/14/26 at 11:42 A.M. an interview with MDS Nurse #523 verified a lack of discharge planning in Resident #4's care plan. The interview further revealed MDS Nurse #523 was not trained to care plan discharge planning and was not responsible for that part of the care plan.2. A review of Resident #85's medical record revealed an admission date of 03/11/26 and a discharge date of 03/21/26. Resident #85's pertinent diagnoses included metabolic encephalopathy, hypertensive heart and chronic kidney disease with heart failure and with stage V chronic kidney disease, type II diabetes mellitus with diabetic chronic kidney disease, asthma, chronic obstructive pulmonary disease (COPD), hyperglycemia, fibromyalgia and dementia.A review of Resident #85's MDS 3.0 assessment dated [DATE] revealed a BIMS score of 09 which indicated impaired cognition. The MDS further revealed Resident #85 was dependent on staff with all ADL, bed mobility and transfers.A review of Resident #85's comprehensive care plan showed no evidence of the resident's preference for discharge planning or resources that were needed to support her plans to return safely to the community.On 05/14/26 at 11:04 A.M. an interview with SSD #515 revealed she was not responsible for any part of the care plan.On 05/14/26 at 11:42 A.M. an interview with MDS Nurse #523 verified a lack of discharge planning in Resident #85's care plan. The interview further revealed MDS Nurse #523 was not trained to care plan discharge planning and was not responsible for that part of the care plan.A review of the MDS Nurse's job description revised June 2019 revealed the MDS Nurse was responsible for development of an individualized, comprehensive resident care plan with the interdisciplinary team ensuring care area triggers were addressed and was expected to ensure care plans were reviewed quarterly and updated as needed to reflect current resident status with individualized problems, goals, and interventions.

Based on medical record review, observation, policy review, and interview, the facility failed to ensure non-pressure related skin impairment was comprehensively assessed. This affected one (Resident #28) of two residents reviewed for non-pressure related skin impairment. The facility census was 77.Findings include:Review of Resident #28's medical record revealed diagnoses including left side weakness and paralysis following a stroke, hypertensive heart and chronic kidney disease, chronic obstructive pulmonary disease, anemia, hidradenitis suppurativa (also known as acne inversa, is a condition that causes small, painful lumps to form under the skin. The lumps usually develop in areas where your skin rubs together, such as the armpits, groin, buttocks and breasts. The lumps heal slowly, recur, and can lead to tunnels under the skin and scarring.), type two diabetes mellitus, and generalized muscle weakness. An admission/Medicare five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #28 was able to make herself understood and was able to understand others. Resident #28 was assessed as cognitively intact.A nursing note dated 04/18/26 at 3:00 P.M. indicated Resident #28 returned from the hospital. Skin areas noted included a purple area to bilateral buttocks and an open area to the left armpit. There was no evidence staff assessed the etiology of the purple areas at that time. A weekly skin check dated 05/08/26 indicated there were skin areas noted which were not new. However, there was no documentation located indicating what the skin areas were.On 05/12/26 at 5:25 P.M., the Director of Nursing (DON) was informed no comprehensive assessments of the skin impairment noted in the 04/18/26 nursing note were located. The DON stated skin was assessed on a weekly basis and Resident #28 had no skin impairment.On 05/13/26 at 10:45 A.M., Licensed Practical Nurse (LPN) #595 stated she assessed Resident #28's skin the evening of 05/12/26 with no skin impairment identified. On 05/14/26 at 10:06 A.M., the DON was asked to provide any information regarding the skin areas referred to during the 05/08/26 weekly skin check.On 05/14/26 at 10:44 A.M., LPN #595 stated she was not informed that impaired skin was documented on the 05/08/26 weekly skin check. Therefore, a more comprehensive assessment of the area had not been completed. LPN #595 stated Resident #28 had chronic areas on her buttocks and her arms not related to pressure, but instead related to the hidradenitis suppurativa. Observations of Resident #28 with LPN #595 revealed a dime sized purple area to the right buttock (not on a bony prominence), a scabbed area to the inferior left buttock and pink/purple area to the left buttock in the area where the buttocks touch (not on a bony prominence). Resident #28 complained of pain when LPN #595 pressed on the superior area of the left buttock which was presenting as pink/purple. While assessing the areas, Resident #28 reported she had dealt with the condition (hidradenitis suppurativa) for years and had a history of one of the areas on the abdomen which had opened previously. LPN #595 verified the areas present on LPN #595's buttocks and it would be important to monitor the skin routinely, especially since Resident #28 complained of one of the areas being painful upon pressure being applied. LPN #595 stated the wound Nurse Practitioner (NP) would have assessed Resident #28's skin after her return from the hospital and provided a note from the NP dated 04/21/26 indicating Resident #28 had purple scarring present to the buttocks due to history of hidradenitis suppurativa. The note indicated no open areas were noted and she would sign off wound care services with a request for further consultation as needed for open wounds. Review of a wound NP note dated 05/15/26 indicated Resident #28 was assessed with abscesses to bilateral buttocks with the primary etiology being hidradenitis suppurativa. The overall measurement was 5 centimeters (cm) x 5 cm x 0.1 cm with 100% epithelial tissue and a light amount of serous (clear or pale yellow) drainage. Review of the facility's Skin Care and Wound Management Overview policy (implementation date not recorded) revealed skin impairment documentation was required for all skin impairment issues that required measurement to indicate if healing was occurring. This deficient practice represents non-compliance investigated under Master Complaint Number 2996672.

Based on observation, interview and record review, the facility failed to ensure timely incontinence care. This affected one resident (#37) of four residents reviewed for bowel and bladder incontinence and had the potential to affect 42 residents (#8, #10, #11, #12, #13, #16, #17, #19, #20, #23, #24, #27, #28, #29, #32, #36, #37, #38, #39, #40, #41, #42, #43, #46, #47, #48, #54, #56, #59, #60, #61, #65, #66, #67, #68, #69, #72, #77, #78, #79, #86, and #89) identified by the facility as incontinent. The facility census was 77.Findings include: A review of medical records for Resident #37 revealed a date of admission [DATE]. Significant diagnosis included chronic respiratory failure with hypoxia (low oxygen level), type II diabetes mellitus, depression, morbid obesity, and need for assistance with personal care. There were no significant orders for the finding.A care plan dated 03/15/26 revealed Resident #37 to be occasionally incontinent of bowel and bladder related to limited mobility, weakness, and obesity. Interventions included checking resident for incontinence, washing, rinsing, and drying perineum, changing clothing as needed after incontinence episodes. A quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) with a score of 15 indicating Resident #37 was cognitively intact. The assessment further revealed Resident #37 was dependent on staff for toileting and hygiene. Resident #37 was always continent of bladder and bowel.On 05/11/26 at 3:30 P.M. an observation of incontinence care for Resident #37 revealed a strong smell of urine in the room. The top sheet was noted to have a light brown liquid on it appearing to be dried urine. A bath blanket that was used as a draw sheet was dotted with a light brown liquid on it that was saturated and seeping under the right leg. This surveyor was able to visualize the saturation on the bath blanket under pad while the top sheet was in place on Resident #37. Upon turning the resident, she was noted to be saturated from the middle of her back to the middle of the thigh. The bath blanket under pad was saturated with a foul smell of urine noted. Upon removal of the bath blanket the bed sheet was noted to be wet from the resident's mid-thigh to the middle back. Resident #37 stated the last time she was placed on the bedpan was yesterday morning. Certified Nurse Aide (CNA) #574 who was rendering the incontinence care verified the strong smell of urine in the room and the other above findings indicating lack of incontinence care for Resident #37 at the time of the observation. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) #519 also verified the findings at the time of the observation. A review of the undated facility policy titled perineal care for male and female revealed perineal care is performed on residents who are unable or unwilling to maintain body cleanliness and are who are incontinent of bowel and bladder. Perineal care will be care planned for each individual resident to meet his or her specific needs, choice, and frequency.This deficiency represents non-compliance investigated under Complaint Number 2668793.

Based on medical record review and interview, the facility failed to maintain accurate and comprehensive medical records for two (Residents #10 and #28) of 34 residents whose records were reviewed. The facility census was 77.Findings include:1. Review of Resident #28's medical record revealed diagnoses including left side weakness and paralysis following a stroke, hypertensive heart and chronic kidney disease, chronic obstructive pulmonary disease, anemia, hidradenitis suppurativa (also known as acne inversa, is a condition that causes small, painful lumps to form under the skin. The lumps usually develop in areas where your skin rubs together, such as the armpits, groin, buttocks and breasts. The lumps heal slowly, recur, and can lead to tunnels under the skin and scarring.), type two diabetes mellitus, and generalized muscle weakness. A skin assessment dated [DATE] indicated Resident #28 had a history of hidradenitis suppurative but had no open areas at the time. On 03/18/26, an order was started for miconazole nitrate powder 2% to be applied to abdominal folds/breast folds topically twice a day for fungal areas for two weeks. A weekly skin check dated 03/20/26 indicated no skin areas were noted. A weekly skin check dated 03/27/26 indicated skin area(s) were noted. However, no documentation was located regarding the skin area(s). A weekly skin check dated 05/08/26 indicated skin area(s) were noted. However, no documentation was located regarding the skin area(s). On 05/14/26 at 10:06 A.M., the Director of Nursing (DON) was informed weekly skin check assessments dated 03/27/26 and 05/08/26 indicated Resident #28 had skin areas but no assessments of the skin areas were able to be located. On 05/14/26 at 10:44 A.M., Licensed Practical Nurse (LPN) #545 stated she was not informed nurses had documented skin areas on 03/27/26 or 05/08/26, so no further assessments were documented. On 05/14/26 at 11:32 A.M., the DON stated she understood the concern regarding staff not documenting skin areas that were observed but upon review of the medical record she believed the nurse who documented the skin issue on 03/27/26 did so because Resident #28 had a treatment to the abdominal and breast folds. The same nurse (LPN #581) had done both assessments in question. On 05/18/26, two written statements by LPN #581 dated 05/15/26 indicated she documented the presence of skin areas on 03/27/26 due to the treatment to the abdominal and breast folds. The statement indicated she had not observed any new or impaired areas at the time of the assessment. The second statement indicated she documented Resident #28 had a skin area noted because staff were applying triad (wound treatment) to bilateral buttocks. LPN #581 indicated she did not observe any new or impaired areas. 2. During an interview on 05/11/26 at 4:15 P.M., Resident #10's listed Power of Attorney (POA) stated she did not feel she was consistently notified of changes in orders/treatment plans. The POA indicated Resident #10 was hard of hearing and did not always understand what was being said to her. Review of Resident #10's medical record revealed diagnoses including dementia, angina pectoris, chronic obstructive pulmonary disease, constipation, major depressive disorder and cognitive communication deficit. A baseline care plan dated 08/21/25 indicated Resident #10 had a communication problem related to hearing problems and dementia. One of the interventions was to include family support. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #10 had moderate difficulty with hearing and was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 7 (out of a possible 15 points). Review of contact information revealed Resident #10 was listed as her own resident representative with her son listed as emergency contact #2 with the niece listed as POA/alternate contact. The designation did not indicate if POA was financial or medical. Review of progress notes revealed there were occasions when staff documented Resident #10's son was notified of changes in orders or results of tests. However, the instances listed below did not reveal any family notification or involvement in decision making and were discussed with the DON on 05/19/26 at 12:31 P.M. - A nurse practitioner note on 01/02/26 indicated the reason for the visit was due to diarrhea and nausea and vomiting that morning. An order was received for a STAT (immediate) KUB (kidney, ureter and bladder) x-ray. There was no documentation of interested parties being notified of the order or of the results. The DON verified no notification of the resident's son or POA being documented. The DON stated when she spoke with the nurse she recalled notifying Resident #10's son of the results, so she did a late entry note on 05/18/26 indicating the results were reported to Resident #10's son. -A telehealth note dated 01/30/26 indicated the nurse reported Resident #10 was more confused than her baseline. Orders were given for a urinalysis/urine culture, hydroxyzine (antihistamine) 25 milligrams (mg) every 12 hours as needed for two days and to call back if Resident #10's condition worsened. The DON stated she spoke with the nurse who recalled calling and leaving a message. On 05/18/26 at 2:35 P.M. the nurse documented Resident #10's POA was updated.

Based on record review, observation, interview, and policy review, the facility failed to follow enhanced barrier precautions (EBP) (an infection control measure used to prevent the spread of multi drug resistant organisms) during wound care. This affected one (Resident #11) of six residents reviewed for infection control and had the potential to affect 17 additional residents (#9, #19, #20, #29, #35, #39, #44, #48, #54, #56, #58, #66, #67, #72, #75, #86, and #87) identified as being on EBP. The facility census was 77.Findings include:A review of medical records for Resident #11 revealed the date of admission as 04/03/19. Significant diagnoses included diabetes mellitus type II. Significant orders included cleanse the right heel with normal saline solution, pat dry, apply collagen to the wound bed, and cover with border foam dressing; cleanse the coccyx area with normal saline solution, pat dry, apply Medi-Honey to alginate and place on wound bed cover with thin layer of Triad paste to the peri area, cover with silicon super absorbent gauze; and EBP related to wounds. A quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating Resident #11 was cognitively intact. The assessment further revealed application of non-surgical dressings, application of ointments, and application of dressings to the feet.A review of the current care plan for Resident #11 revealed the resident required EBP. Interventions included appropriate personal protective equipment (PPE) will be utilized during high contact activities.Observation of wound care on 05/13/26 at 10:05 A.M. with Licensed Practical Nurse (LPN) #595 who was identified as the facility wound care nurse revealed a wound to Resident #11's coccyx. LPN #595 did not utilize a gown during the wound care observation. LPN #595 verified she did not utilize the gown during care and stated, she forgot.A review of the undated facility policy titled; Enhanced Barrier Precautions Revealed enhanced barrier precautions refers to an infection control intervention designed to reduce transmission of multi drug resistant organism that employs hand hygiene, targeted gown and glove use during high contact resident care activities that include dressing, bathing and showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of central lines, urinary catheter care, feeding tube care, tracheostomy ventilator care, wound care and any opening requiring a dressing. The policy further revealed EBP are indicated for residents with any of the following including wounds. and or indwelling medical devices.This deficiency represents noncompliance identified under Master Complaint Number 2996672.

Based on record reviews and interviews, the facility failed to notify the State Ombudsman of transfers or discharges for four Residents (#3, #4, #28, and #85) of six residents reviewed for proper discharge processes. The facility census was 77.Findings include: 1. A review of Resident #3's medical record revealed an admission date 04/29/26 and a discharge date of 05/07/26. Resident #3's pertinent diagnoses included surgical aftercare following surgery on the digestive system, incisional hernia without obstruction or gangrene, malignant neoplasm of cervix uteri, type II diabetes mellitus with hyperglycemia, atrial fibrillation, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), asthma, aphasia and depression. A review of Resident #3's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS also revealed Resident #3 required supervision with all activities of daily living (ADL), transfers and mobility. A nursing note written on 05/07/26 at 4:30 P.M. revealed Resident #3 discharged home per Nurse Practitioner (NP) order. The nurse reviewed the face sheet, orders and the discharge summary with the resident. Resident #3 exited the facility accompanied by son and with all belongings and without injury. On 05/13/26 at 12:30 P.M. an interview with the Administrator verified she was unable to find evidence that discharge notices were sent to the Ombudsman at time of discharge or as soon as possible afterward. On 05/14/26 at 10:58 A.M., an interview with Social Service Designee (SSD) #515 verified she had not notified the Ombudsman's office of Resident #3's discharge. 2. A review of Resident #4's medical record revealed an admission date of 04/27/26 and a discharge date of 05/06/26. Resident #4's pertinent diagnoses included malignant neoplasm of parotid gland, sciatica, encounter for other plastic and reconstructive surgery following medical procedure or healed injury, peripheral vascular disease (PVD), hypertensive heart disease, hearing loss, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, hypothyroidism, delirium due to known physiological condition. A review of Resident #4's MDS 3.0 assessment dated [DATE] revealed a BIMS score of 15 which indicated intact cognition. The MDS also revealed Resident #4 required substantial/maximum assistance with all ADL and partial assistance with bed mobility and transfers. A nursing note written on 05/06/26 at 10:40 A.M. revealed Resident #4 discharged per NP order. The nurse reviewed the discharge summary and orders with the resident's son, and the son had no questions or concerns. The resident exited the facility via wheelchair accompanied by a transportation company and family. The resident exited the facility with all belongings and without injury. On 05/13/26 at 12:30 P.M. an interview with the Administrator verified she was unable to find evidence that discharge notices were sent to the Ombudsman at time of discharge or as soon as possible afterward. On 05/14/26 at 10:58 A.M., an interview with SSD #515 verified she had not notified the Ombudsman's office of Resident #4's discharge. 3. A review of Resident #85's medical record revealed an admission date of 03/11/26 and a discharge date of 03/21/26. Resident #85's pertinent diagnoses included metabolic encephalopathy, hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, type II diabetes mellitus with diabetic chronic kidney disease, asthma, COPD, hyperglycemia, fibromyalgia and dementia. A review of Resident #85's MDS 3.0 assessment dated [DATE] revealed a BIMS score of 09 which indicated impaired cognition. The MDS further revealed Resident #85 was dependent on staff with all ADL, bed mobility and transfers. A nursing note written on 03/21/26 at 10:10 P.M. revealed Resident #85 was discharged home per doctor's order. The nurse attempted to review discharge orders and face sheet with the resident's daughter and daughter stated, 'We are in a hurry as they will leave and not wait on us, I know how to give her pills.' Resident #85's daughter signed the discharge papers as requested. The resident exited the facility in a wheelchair without injuries. On 05/13/26 at 12:30 P.M. an interview with the Administrator verified she was unable to find evidence that discharge notices were sent to the Ombudsman at time of discharge or as soon as possible afterward. On 05/14/26 at 10:58 A.M., an interview with SSD #515 verified she had not notified the Ombudsman's office of Resident #85's discharge. 4. Review of Resident #28's medical record revealed diagnoses including hemiplegia and hemiparesis following a stroke, chronic kidney disease, anxiety disorder, COPD and hypertensive heart disease. A nursing note dated 04/15/26 at 1:50 P.M. indicated Resident #28 called 911 from her room, refusing evaluation by the NP. Resident #28 complained of chest pain and was transferred to the hospital. A nursing note dated 04/16/26 at 12:43 A.M. indicated Resident #28 was admitted to the hospital for chest pain. On 05/14/26 at 10:58 A.M., SSD #515 verified she had not notified the Ombudsman's office of Resident #28's transfer to the hospital.

Based on record review, observation, interview and policy review, the facility failed to ensure the treatment was completed as ordered for Resident #47's right lateral nose skin cancer. This finding affected one (Resident #47) of four residents reviewed for general skin conditions. The facility census was 72. Findings include: Review of the medical record revealed Resident #47 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including malignant melanoma of the nose, cognitive communication deficit and weakness. Review of Resident #47's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #47's Wound Assessment Report form authored by Wound Nurse Practitioner (NP) #584 dated 04/25/25 revealed the resident had a right nostril melanoma wound identified on 04/02/25 which measured 2.0 centimeters (cm) length by 2.30 cm width by 0.10 cm depth. The treatment included cleansing the wound daily with normal saline and leave open to air (OTA). Review of Resident #47's Wound Assessment Report form authored by Wound NP #584 dated 05/05/25 revealed the resident had a right nostril melanoma wound which measured 2.0 cm length by 2.30 cm width by 0.10 cm depth. The treatment indicated cleansing the wound with normal saline daily and OTA. Review of Resident #47's Wound Assessment Report form authored by Wound NP #584 dated 05/19/25 revealed the resident had a right nostril melanoma which measured 2.0 cm length by 2.30 cm width by 0.10 cm depth. The treatment indicated cleansing the wound with normal saline daily and leave OTA. Review of Resident #47's medication administration records (MARS) and treatment administration records (TARS) from 04/25/25 to 05/20/25 did not reveal evidence the resident's right nostril was cleansed daily with normal saline as ordered by Wound NP #584. Interview on 05/20/25 at 7:46 A.M. with Registered Nurse (RN) Wound Nurse #562 confirmed Resident #47's medical record did not have evidence the resident's right nostril was cleansed daily with normal saline and left OTA. Review of the undated Skin Care and Wound Management Overview policy revealed the facility staff strived to prevent resident skin impairment and to promote the healing of existing wounds.

Based on record review, observation, interview and policy review, the facility failed to ensure a medication error rate of 5% or less. This finding affected one (Residents #8) of two residents observed for medication administration. A total of 30 medications were administered with two errors for a medication error rate of 6.67%. Findings include: Review of Resident #8's medical record revealed the resident was admitted on [DATE] with diagnoses including type two diabetes, weakness and anemia. Review of Resident #8's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #8's physician orders revealed an order dated 05/20/24 for Omega-3 fish oil administer 1000 milligrams (mg) by mouth two times a day for a supplement; and an order dated 12/12/24 for Humalog KwikPen (insulin) inject six units subcutaneously (sq) with meals for diabetes. Observation on 05/18/25 at 8:11 A.M. with Registered Nurse (RN) #565 of Resident #8's morning medication administration revealed four medications were administered with two errors. RN #565 did not prime the resident's Humalog KwikPen prior to administering the resident's Humalog insulin and the resident's fish oil was administered at 500 mg instead of 1000 mg as ordered. Interview on 05/18/25 at 9:45 A.M. with RN #565 confirmed the nurse did not prime Resident #8's Humalog KwikPen prior to administering the resident's insulin and administered 500 mg of the fish oil instead of 1000 mg as ordered. Review of the Instructions for Use of the Humalog Kwikpen, revised 03/31/20, revealed to prime the pen by turning the dose knob to select two units; hold the pen with the needle point up and tap the cartridge holder gently to collect air bubbles at the top; continue holding the pen with the needle point up and push the dose knob in until it stops and the 0 was seen in the dose window. Insulin should be observed at the tip of the needle. Select the dose and administer the insulin. Review of the Liberalized Medication Administration policy indicated it was the policy of the facility to administer medications to residents in a safe manner but in a way that correlates with their daily activities and natural schedules.

Based on medical record review, facility investigation review, self-reported incident review, facility policy review, and interviews, the facility failed to timely report an allegation of sexual abuse. This affected three (Resident #7, #10, and 14) of four residents reviewed for abuse. The facility census was 77. Findings include: Medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including hemiparesis and hemiplegia following cerebral infarction, schizophrenia, history of substance abuse, muscle weakness, dysphagia, and chronic obstructive pulmonary disease. Further review of the medical record revealed the resident was severely cognitively impaired. Medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, chronic kidney disease, bipolar disorder, panic disorder, and history of cocaine abuse, and chronic obstructive pulmonary disease. Further review of the medical record revealed the resident was moderately cognitively impaired. Medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including chronic heart failure, acute pancreatitis, depression, anxiety disorder, personal history of trauma, other stimulant abuse, and muscle weakness. Further review of the medical record revealed the resident was cognitively intact. Review of Self-Reported Incident (SRI) #248991, dated 06/24/24, revealed on 06/23/24 Licensed Practical Nurse (LPN) #58 reported to the Director of Nursing (DON) that she had been told by a resident, who heard from another resident, that there was fornication on the smokers' patio with a couple of residents. The residents alleged to be involved were Resident (#7, #10, and #14). The allegation was immediately reported to the Administrator and an investigation was immediately initiated. Following the allegation, the smoking patio was supervised by staff during smoking breaks for all residents. The three residents in question were interviewed with no concerns, and there were no witnesses who confirmed that fornication had occurred on the patio. Interview on 06/27/24 at 1:00 P.M. with the Administrator confirmed the sexual abuse allegation indicated in SRI #248991 was not reported to the State Agency within two hours as required. Review of the facility's policy titled, Ohio Abuse, Neglect, and Misappropriation, dated 10/27/21, revealed all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of property, are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. This deficiency represents non-compliance investigated under Complaint Number OH00155131.

Based on medical record review, self-reported incident review, facility policy review, and interviews, the facility failed to complete an accurate smoking risk assessment for two residents (#7 and #12) and failed to ensure smoking supervision for Resident #7, who was severely cognitively impaired. This affected two (Resident #7 and #12) of four residents reviewed for accidents. The facility census was 77. Findings include: 1. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including hemiparesis and hemiplegia following cerebral infarction, schizophrenia, history of substance abuse, muscle weakness, dysphagia (difficulty swallowing), and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/30/24, revealed the resident was severely cognitively impaired. Review of a physician progress note, dated 06/18/24, revealed Resident #7 had the diagnoses of hemiplegia, hemiparesis, dysphagia, and contractures of the right hand/finger. Review of Resident #7's Smoking Assessment v 4, dated 05/24/24, indicated the resident was an independent smoker. The assessment incorrectly indicated that the resident did not have dexterity problems, did not have swallowing difficulties, and that the plan of care reflected the use of nicotine in any form. Review of Self-Reported Incident (SRI) #248991, dated 06/24/24, revealed on 06/23/24 Resident #7 was unsupervised during a smoke break when an allegation of potential sexual abuse occurred. Interview on 06/26/24 at 12:55 P.M. with the Director of Nursing (DON) confirmed Resident #7's smoking assessment dated [DATE] was incorrect and she would re-assess the resident. The DON further confirmed Resident #7's care plan did not indicate the use of nicotine or that the resident was a smoker and that it should have been revised to reflect she used nicotine. Following Resident #7's smoking re-assessment completed by the DON during the complaint investigation revealed the resident had a dexterity problem, swallowing difficulties, and required smoking supervision. Interview on 06/26/24 at 4:15 P.M. with the Administrator confirmed Resident #7 had been unsupervised during her smoking breaks, but going forward she will be supervised during her smoking breaks. 2. Medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including infarction, dementia, diabetes mellitus, psychotic disturbance, mood disturbance, anxiety, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 03/29/24, revealed the resident was moderately cognitively impaired and had a diagnosis of dementia. Review of Resident #12's Smoking Assessment v 4, dated 06/20/24, incorrectly revealed the resident did not have a diagnosis of dementia. Interview on 06/26/24 at 4:20 P.M. with the Administrator confirmed Resident #12's smoking assessment incorrectly indicated the resident did not have a diagnosis of dementia. Review of the facility's policy titled, Resident Smoking Guidelines, undated, revealed it is the policy of the facility to promote resident centered care by providing a safe smoking area for residents that request to smoke and are capable of safe smoking behaviors either independently or with supervision. Assessment, observation, and designation of independent or supervised smoker will be made by the interdisciplinary team (IDT) for each resident who requests to smoke in the facility. The smoking assessment includes the assessment of the level of dexterity to manage smoking and smoking materials.

Based on medical record review, self-reported incident (SRI) review, facility investigation review, facility policy review, and interview, the facility failed to maintain complete medical records. This affected three (Resident #7, #10, and #14) of four residents reviewed for abuse. The facility census was 77. Findings include: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including hemiparesis and hemiplegia following cerebral infarction, schizophrenia, history of substance abuse, muscle weakness, dysphagia, and chronic obstructive pulmonary disease. Further review revealed the resident was severely cognitively impaired. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, chronic kidney disease, bipolar disorder, panic disorder, and history of cocaine abuse, and chronic obstructive pulmonary disease. Further review revealed the resident was moderately cognitively impaired. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including chronic heart failure, acute pancreatitis, depression, anxiety disorder, personal history of trauma, other stimulant abuse, and muscle weakness. Further review revealed the resident was cognitively intact. Review of Self-Reported Incident (SRI) #248991, dated 06/24/24, revealed on 06/23/24 Licensed Practical Nurse (LPN) #58 reported to the Director of Nursing (DON) that she had been told by a resident, who heard from another resident, that there was fornication on the smoker's patio with a couple of residents. The residents alleged to be involved were Resident (#7, #10, and #14). The allegation was immediately reported to the Administrator and an investigation was immediately initiated. Following the allegation, the smoking patio was supervised by staff during smoking breaks for all residents. The three residents in question were interviewed with no concerns, and there were no witnesses who confirmed that fornication had occurred on the patio. Review of Resident (#7, #10, and #14's) medical records revealed no documentation of the alleged incident of sexual abuse as indicated in SRI #248991. Interview on 06/24/24 at 3:16 P.M. with the Administrator confirmed Resident #7, #10, and #14's medical records did not contain documentation of the incident indicated in SRI #248991. The Administrator further confirmed the incident should have been documented in Resident #7, #10, and #14's medical records. Review of the facility's policy titled, Ohio Abuse, Neglect, and Misappropriation, dated 10/27/21, revealed investigation of incidents: documentation of the facts and findings will be completed in each resident medical record and the physician of each resident will be notified. This deficiency represents non-compliance investigated under Complaint Number OH00155131.

Based on observation, review of physician orders, review of medication information from Medscape and interview, the facility failed to ensure medications were administered in accordance with physician orders and manufacturer information. Four medication errors were identified out of 38 opportunities resulting in a 10.5% medication error rate. This affected three (Residents #11, #14, and #28) of three residents observed for medication administration. Findings include: 1. On 10/02/23 at 8:46 A.M., Licensed Practical Nurse (LPN) #100 was observed administering medication to Resident #14. Among the medications administered was hydralazine (a vasodilator) 25 milligrams (mg). Review of Resident #14's physician order sheet revealed an order dated 03/22/23 for hydralazine 25 mg with instructions to administer three tablets every eight hours for hypertension. On 10/02/23 at 10:17 A.M., LPN #100 verified she only gave one of the hydralazine but should have administered three. 2. On 10/02/23 at 9:03 A.M., Registered Nurse (RN) #101 was observed administering medication to Resident #28. Among the medications administered were enteric coated aspirin 81 mg and isosorbide mononitrate (anti-anginal) extended release (ER) 60 mg. The medications were crushed prior to administration. Review of Resident #28's physician order sheet revealed an order dated 12/18/22 that medications could be crushed unless contraindicated. On 12/18/22 an order was written for enteric coated aspirin 81 mg in the morning. On 12/18/22 an order was written for isosorbide mononitrate ER 60 mg in the morning. Review of medication information from Medscape revealed enteric coated aspirin should not be crushed because it could release all of the drug at once increasing the risk of side effects. Medscape revealed the extended release isosorbide mononitrate must not be crushed. On 10/02/23 at 9:08 A.M., RN #101 verified the enteric coated aspirin was crushed, stating Resident #28 did not like the taste of chewable aspirin. At 10:14 A.M., RN #101 verified she also crushed the enteric coated isosorbide mononitrate. 3. On 10/02/23 at 9:26 A.M., LPN #102 was observed administering medication to Resident #11. Among the medications administered was tetrahydrozoline HC 0.05% eye drops with one drop applied in both eyes. Review of Resident #11's physician order sheet revealed an order dated 02/17/23 for polyvinyl alcohol ophthalmic solution 1.4%: instill one drop in both eyes three times a day. There was no order for tetrahydrozoline eye drops. On 10/02/23 at 10:25 A.M., LPN #102 verified she had administered tetrahydrozoline eye drops and was uncertain if they were interchangeable with polyvinyl alcohol eye drops. On 10/02/23 at 10:56 A.M., Pharmacist #103 verified the tetrahydrozoline and polyvinyl eye drops were not interchangeable. This deficiency represents non-compliance investigated under Complaint Number OH00146516 and is an example of continued non-compliance from the survey dated 09/14/23.

Based on observation and interview, the facility failed to have sufficient dietary staff to serve meals timely. This had the potential to affect 70 of 70 resident who received meals from the kitchen, as Resident #60 received no food by mouth. The facility census was 71. Findings include: Review of the facility dining times revealed the lunch meal was to start serving at 11:30 A.M. Interview on 09/11/23 at 8:30 A.M. with Registered Dietician (RD) #900 revealed three dietary staff called off work today including the cook. She stated the Food Service Director (FSD) #867 was acting as the cook. Interview on 09/11/23 at 8:47 A.M. with Social Service Designee (SSD) #805 revealed she was assisting with meal service due to three call-offs. She stated other staff have assisted with dietary in the past due to call-offs or insufficient staffing. Interviews on 09/11/23 from 9:00 A.M. through 11:30 A.M. during the screening process for the annual survey with multiple residents (# 9, #13, #16, #17, #19, #, 26, #36, #38, #45, #58, #64, #171 and #175) revealed multiple concerns with dietary including staffing, temperatures and timeliness of meals. Interview on 09/11/23 at 9:43 A.M. with FSD #867 revealed she was new to the facility, approximately ten days. She stated she had three call-offs and was acting as the cook. She stated she had a meeting with her team the prior week about her expectations as she stated she had a lot of issues in the kitchen and would most likely be terminating everyone and starting with new staff. Observation on 09/11/23 from 11:30 A.M. to 2:37 P.M. revealed the lunch meal was not served until 2:17 P.M. Observation n 09/11/23 at 1:49 P.M. of the dining room revealed Resident #51 was sitting at a table in the dining room. Interview at the time of observation with Resident #51 stated he had been sitting in the dining room since 11:30 A.M. waiting for lunch and he had not yet received lunch. Observation on 09/11/23 at 2:01 P.M. revealed Resident #16 was coming back from her room after making sandwiches for her and her tablemates (#17 and #19) as they were still waiting for lunch. Interview on 09/11/23 at 2:04 P.M. with Licensed Practical Nurse (LPN) #870 verified lunch had not been served yet. She stated the hall trays were usually delivered between 12:00 P.M. and 1:00 P.M. and they were running very late this day. A subsequent interview on 09/11/23 at 3:13 P.M. and on 09/14/23 at P.M. with FSD #867 revealed lunch was late on 09/11/23 due to her being on her own to prepare the meal. Review of a list of resident diets revealed Resident #60 received no food by mouth. Review of the facility policy titled Department Staffing, last revised 09/2017, revealed the dining services department would employ sufficient staff to carry out the functions of food and nutrition services that is safe and effective. This deficiency represents non-compliance investigated under Complaint Number OH00146369.

Based on record review, observation and interviews the facility failed to ensure food was served at a palatable temperatures. This had the potential to affect 70 of 70 resident who received food from the kitchen, as Resident #60 received no food by mouth. The facility census was 71. Findings include: Interviews on 09/11/23 from 9:00 A.M through 11:30 A.M. during the screening process for the annual survey with multiple residents (# 9, #13, #16, #17, #19, #, 26, #36, #38, #45, #58, #64, #171 and #175) revealed concerns with dietary including palatability of meals. Observation and interview on 09/12/23 at 11:35 A.M. revealed the hot food on the steam table had temperatures over 165 degrees. A test tray left the steam table at 12:15 P.M. The test tray was served last at 12:34 P.M. The culinary director from sister facility (CD) #910 proceeded to take the temperatures of the meal. The chicken thigh was 123 degrees, the mashed potatoes were 130 degrees and the peas were 127 degrees. CD #910 revealed the food should be over 135 degrees. Review of a list of resident diets revealed Resident #60 received no food by mouth. Review of the facility policy titled Food Preparation, last revised 09/2017 revealed all foods will be held at appropriate temperatures, greater than 135 degrees for hot food holding. This deficiency represents non-compliance investigated under Complaint Numbers OH00146369.

Based on observation and interview, the facility failed to serve meals in a timely manner. This had the potential to affect 70 of 70 residents who received food from the kitchen. Resident #60 received no food by mouth. The facility census was 71. Findings include: 1. Review of the facility dining times revealed the lunch meal was to start serving at 11:30 A.M. Interview on 09/11/23 at 8:30 A.M. with Registered Dietician (RD) #900 revealed three dietary staff called off work today including the cook. She stated the Food Service Director (FSD) #867 was acting as the cook. Interview on 09/11/23 at 8:47 A.M. with Social Service Designee (SSD) #805 revealed she was assisting with meal service due to three call-offs. She stated other staff have assisted with dietary in the past due to call-offs or insufficient staffing. Interviews on 09/11/23 from 9:00 A.M. through 11:30 A.M. during the screening process for the annual survey with multiple residents (# 9, #13, #16, #17, #19, #, 26, #36, #38, #45, #58, #64, #171 and #175) revealed multiple concerns with dietary including staffing, temperatures and timeliness of meals. Interview on 09/11/23 at 9:43 A.M. with FSD #867 revealed she was new to the facility, approximately ten days. She stated she had three call-offs and was acting as the cook. She stated she had a meeting with her team the prior week about her expectations as she stated she had a lot of issues in the kitchen and would most likely be terminating everyone and starting with new staff. Observation on 09/11/23 from 11:30 A.M. to 2:37 P.M. revealed the lunch meal was not served until 2:17 P.M. Observation n 09/11/23 at 1:49 P.M. of the dining room revealed Resident #51 was sitting at a table in the dining room. Interview at the time of observation with Resident #51 stated he had been sitting in the dining room since 11:30 A.M. waiting for lunch and he had not yet received lunch. Observation on 09/11/23 at 2:01 P.M. revealed Resident #16 was coming back from her room after making sandwiches for her and her tablemates (#17 and #19) as they were still waiting for lunch. Interview on 09/11/23 at 2:04 P.M. with Licensed Practical Nurse (LPN) #870 verified lunch had not been served yet. She stated the hall trays were usually delivered between 12:00 P.M. and 1:00 P.M. and they were running very late this day. A subsequent interview on 09/11/23 at 3:13 P.M. and on 09/14/23 at P.M. with FSD #867 revealed lunch was late on 09/11/23 due to her being on her own to prepare the meal. Review of a list of resident diets revealed Resident #60 received no food by mouth. Review of the facility policy titled Frequency of Meals, last revised 09/2017, revealed at least three meals would be provided at regular times comparable to normal mealtimes in the community. 34297 2. Review of Resident #58's medical record revealed the resident was admitted on [DATE] with diagnoses including type two diabetes with diabetic neuropathy, chronic pain syndrome and essential hypertension. Review of Resident #58's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #58's physician orders revealed an order dated 08/22/23 for Humalog FlexPen (fast-acting insulin) inject 15 units subcutaneously before meals for diabetes mellitus. Observation on 09/11/23 at 1:52 P.M. revealed Licensed Practical Nurse (LPN) #803 obtained Resident #58's blood sugar with a result of 78. An additional observation on 09/11/23 at 1:55 P.M. revealed Resident #58 refused her Humalog insulin because the meal tray was late and her blood sugar was running low. Interview on 09/11/23 at 2:00 P.M. with LPN #803 confirmed Resident #58 refused her Humalog insulin because her meal tray was late and her blood sugar was low. Review of the facility dining times revealed the lunch meal was to start serving at 11:30 A.M. This deficiency represents non-compliance investigated under Complaint Numbers OH00146369 and OH00145609.

Based on record review and interview, the facility failed to ensure Resident #2's care plan meetings were completed at least quarterly. This finding affected one (Resident #2) of four residents investigated for care planning. Findings include: Review of Resident #2's medical record revealed an initial admitted [DATE] with a readmitted [DATE]. Diagnoses include acute respiratory failure with hypoxia, hypertensive heart disease and history of falling. Review of Resident #2's Minimum Data Set (MDS) 3.0 comprehensive assessment revealed the resident exhibited severe cognitive impairment. Review of Resident #2's Care Conference Review form dated 11/15/22 revealed staff conducted a care conference. Review of Resident #2's progress note dated 05/11/23 at 3:25 P.M. indicated the daughter was called to discuss the resident's code status and hospice services. Review of Resident #2's medical record did not reveal other documentation on care planning. Interview on 09/13/23 at 9:40 A.M. with the Director of Nursing (DON) confirmed care conferences were not completed quarterly to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure the comprehensive care plan was reviewed and revised by an interdisciplinary team composed of individuals who had knowledge of the resident and her needs, and that each resident and resident representative was involved in developing the care plan and making decisions about the care received. Review of the undated Plan of Care policy indicated it was the policy of the facility to provide resident care that meets the psychosocial, physical and emotional needs and concerns of the residents. The purpose of the policy is to provide guidance to the facility to support the inclusion of the resident or resident representative in all aspects of person-centered care planning and that this planning includes the provision of services to enable the resident to live with dignity and support the goals, choice and presence.

Based on observation, record review and interview, the facility failed to ensure a medication error rate of less than 5%. A total of 26 medications were administered with five medication errors for a medication error rate of 19.23%. This finding affected three residents (Residents #32, #53 and #66) of six residents observed for medication administration. Findings include: 1. Review of Resident #32's medical record revealed the resident was admitted on [DATE] with diagnoses including heart failure, fibromyalgia and diabetes. Review of Resident #32's physician orders revealed an order dated 06/18/20 for Cymbalta give 60 mg (milligrams) by mouth in the morning for major depression and give 60 mg by mouth at bedtime for depression; an order dated 11/11/22 for Lasix 20 mg (diuretic) give one tablet by mouth in the morning for edema; and an order dated 01/05/23 for artificial tears instill one drop in both eyes every morning and at bedtime for dry eyes. Observation on 09/11/23 at 9:57 A.M. with Licensed Practical Nurse (LPN) #801 of Resident #32's medication administration revealed twelve medications were administered. LPN #801 did not administer Resident #32's Cymbalta, Lasix and artificial tears as ordered; however, she documented on the MAR that she had administered the medications. Interview on 09/11/23 at 12:13 P.M. with LPN #801 confirmed she did not administer Resident #32's Cymbalta, Lasix and artificial tears for a total of three medication errors. 2. Review of Resident #53's medical record revealed the resident was admitted on [DATE] with diagnoses including hypertensive heart disease, heart failure and diabetes. Review of Resident #53's physician orders revealed an order dated 08/10/23 for NovoLog fast acting insulin inject 8 units subcutaneously before meals for diabetes. Observation on 09/11/23 at 1:52 P.M. with LPN #803 revealed she administered two medications to Resident #53 including NovoLog insulin via a FlexPen. LPN #803 administered 8 units of NovoLog insulin via a FlexPen and did not prime the pen with two units of insulin prior to dialing up 8 units of insulin and administering the insulin to the resident. Interview on 09/11/23 at 2:22 P.M. with LPN #803 confirmed she did not prime Resident #53's NovoLog FlexPen as required prior to dialing up 8 units of the insulin and administering the insulin to the resident for a total of one medication error. Review of the undated NovoLog Insulin Using Your FlexPen prescriber instructions indicated to wash and dry your hands, remove the pen cap, gently roll the pen ten times between the hands, wipe the rubber end of the pen with an alcohol swab, remove the seal from the new pen needle and screw it onto the end of the pen, remove the outer needle cap and set aside, remove the inner needle cap and throw away, turn the knob on the pen to a dose of 2 units, hold the pen with the needle straight up, tap the side of the pen to get rid of any air bubbles, push the injection button until you see zero in the dose window, turn the knob on the end of the pen to the desired dose, use an alcohol swab to clean the skin, insert the needle straight into the skin so that it reaches the fatty lay, use your thumb to slowly press the button on the end of the pen all the way in and hold it for 10 seconds to allow time for the insulin to get into the body. 3. Review of Resident #66's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including hypothyroidism, anxiety disorder and epileptic syndromes with complex partial seizures. Review of Resident #66's physician orders revealed an order dated 08/22/23 for Zonisamide oral capsule 100 mg give three capsules by mouth every morning and at bedtime for convulsion. Observation on 09/11/23 at 10:16 A.M. with LPN #802 of Resident #66's medication administration revealed eleven medications were administered. LPN #802 did not administer Resident #66's Zonisamide anticonvulsant as ordered. Interview on 09/11/23 at 12:00 P.M. with LPN #802 confirmed she did not administer Resident #66's Zonisamide anticonvulsant as ordered for a total of one medication error. A total of 26 medications were administered with five medication errors for a medication error rate of 19.23 percent. Review of the undated Medication Administration policy revealed the facility would properly assess residents and plan their care to meet these needs. Medications which were ordered by the physician for a specific time will be given as such. Utilization of the liberalized medication administration structure does not imply that any time frame parameter was acceptable for providing medications. Specific medications may still require strict parameters determined by the physician.

Based on observation, record review and interview, the facility failed to ensure Resident #39 received the appropriate food items to meet dietary needs identified on meal tickets. This finding affected one (Resident #39) of two residents reviewed for nutrition. The facility census was 71. Findings include: Review of Resident #39's medical record revealed the resident was readmitted to the facility on [DATE] with diagnoses including hemiplegia, unspecified dementia and epilepsy. Review of Resident #39's Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #39's nutritional care plan revealed an intervention dated 05/12/23 to provide meals per the dietary order. Review of Resident #39's physician orders revealed an order dated 07/06/23 for a regular diet, pureed texture and regular consistency. Review of Resident #39's dietary meal ticket dated 09/11/23 for the breakfast meal indicated the resident was to receive pureed bananas foster french toast, pureed breakfast ham with brown gravy, pureed fortified hot cereal of choice, assorted yogurt cup, 2% (percent) milk, hot coffee and orange juice. Observation on 09/11/23 at 9:20 A.M. with Licensed Practical Nurse (LPN) #802 of Resident #39's breakfast meal tray revealed the resident was served pureed bananas foster french toast, pureed breakfast ham, 2% milk, coffee and orange juice. Interview on 09/11/23 at 9:24 A.M. with LPN #802 confirmed Resident #39 was not served the pureed fortified hot cereal of choice and assorted yogurt cup as ordered on her dietary meal ticket. Review of Resident #39's dietary meal ticket dated 09/12/23 for the breakfast meal indicated the resident was to receive pureed baked cheese omelet, pureed sausage patty, pureed oatmeal, pureed English muffin, yogurt cup, 2% milk, hot coffee and orange juice. Observation on 09/12/23 at 8:16 A.M. with State tested Nursing Assistant (STNA) #804 revealed Resident #39's breakfast tray was delivered which included a pureed cheese omelet, pureed sausage patty with brown gravy, pureed English muffin, 2% milk, hot coffee and orange juice. No yogurt cup or pureed oatmeal cereal were on the tray and STNA #804 indicated she would get the yogurt cup for the resident. Interview on 09/12/23 at 8:43 A.M. with the Administrator confirmed Resident #39's pureed oatmeal and yogurt cup were not on the breakfast tray served to the resident. Review of Meal Distribution policy revised 09/2017 indicated meals were transported to the dining locations in a manner that ensured proper temperature, maintenance, protects against contamination and were delivered in a timely manner and all meals would be assembled in accordance with the individualized diet order, plan of care, and preferences. This deficiency represents non-compliance investigated under Master Complaint Number OH00146369.

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of hospital discharge records, fall investigation and root cause analysis review, resident and staff interviews, facility policy review, and manufacturer's guideline review, the facility failed to provide Resident #50 with a safe transfer using a mechanical lift. Actual harm occurred to Resident #50 when the resident received assistance from two staff members, who failed to use the proper weight capacity lift and used the mechanical lift incorrectly by not widening the base of the lift prior to use, resulting in an avoidable fall with injury including a fractured left distal radius. This affected one resident (Resident #50) of three residents reviewed for falls. The facility census was 65. Findings include: Review of Resident #50's medical record revealed an admitted [DATE] with diagnoses that included congestive heart failure, severe morbid obesity, chronic obstructive pulmonary disease, and diabetes mellitus. Review of the fall risk assessment dated [DATE] indicated Resident #50 was at a high risk for falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50 had an intact cognition level and required total dependence of two staff persons for transfers using a mechanical lift. Review of Resident #50's care plan dated 06/24/21 revealed she was at risk for falls due to decreased mobility and was to utilize a mechanical lift. Review of the physician's orders for Resident #50, dated 12/01/22, the resident was to be transferred using the mechanical lift with the assistance of two staff members. Review of the weights for Resident #50 revealed on 05/05/23 the resident had a weight of 438.8 pounds. Review of Resident #50's nursing notes revealed on 05/10/23 a late entry progress note stated during a transfer utilizing a mechanical lift with two staff members the lift tipped over causing Resident #50 to fall to the floor and the lift landed on the resident. At this time, Resident #50 was assessed by the nurse. Resident #50 complained of pain to her left wrist. Resident #50 was sent to the emergency room for evaluation. Upon returning to the facility Resident #50 was found to have a fracture to the left distal radius with a new splint applied for immobilization. Review of the hospital discharge records 05/10/23 including orthopedic evaluation revealed a new left distal radius fracture after falling from a mechanical lift. A new splint for immobilization was applied. Hospital records indicated Resident #50 had a current weight of 452.3 pounds. Review of the facility fall investigation completed on 05/10/23 revealed Resident #50 was being transferred by a mechanical lift and two State tested Nurse Aide (STNA) #133 and STNA #141. The lift tipped over causing Resident #50 to fall and the lift fell on the resident. Resident #50 was assessed, the physician notified and the resident was sent to the hospital. Review of the facility Root Cause Analysis of the fall incident dated 05/10/23 revealed staff members failed to use the correct size mechanical lift and also failed to widen the base of the lift which caused the lift to tip over during transfer of the resident. Interview with Resident #50 on 06/13/23 at 11:05 A.M. revealed last month during a mechanical lift transfer from bed to wheelchair with two staff members, the lift tipped over due to staff not widening the base of the lift and using the wrong size lift. Resident #50 indicated the lift tipped over causing her to fall to the ground and then the lift fell on top of her. She was sent to the hospital and found to have a fracture to the left wrist. Interview with STNA #133 on 06/14/23 at 2:00 P.M. revealed she was assisting another STNA in transferring Resident #50 using a mechanical lift and the base legs where not widened prior to lifting and moving the resident. Interview with the Administrator and Director of Nursing (DON) on 06/13/23 at 12:25 P.M. revealed Resident #50 suffered a fall during a mechanical lift transfer with two STNAs due to staff members using the wrong size mechanical lift and not widening the base of the mechanical lift. The fall resulted in a fracture to the resident's left distal radius. They indicated the 450-pound lift was utilized when the resident was determined to be 452 pounds at the hospital. They indicated staff should have used the 600-pound lift. Review of the undated facility policy titled Mechanical Lifts and Transfers indicated staff are to use the appropriate size lift and when transporting a resident from one location to another using a lift, the legs of the lift must remain in the maximum open position for optimum stability and safety while the lift is moving. Review of the undated mechanical lift manufacturer's guidelines indicated the following: Lifting the Patient - When using an adjustable base lift, the legs must be in the maximum opened/locked position before lifting the patient. The deficient practice was corrected on 05/10/23, when the Administrator and DON provided staff education of mechanical lift procedures to 54 staff members and the facility implemented the following corrective measures: On 05/10/23, Resident #50 was sent to the local emergency department for evaluation and treatment. On 05/10/23 a Root Cause Analysis was completed by the Administrator which determined staff failed to follow mechanical lift policy and procedure by using the incorrect size mechanical lift and not widening the base of the lift. On 05/10/23 all medical staff including 38 STNA and 16 licensed nurses were educated on the mechanical lift policy and procedure. On 05/10/23 all medical staff that were in the facility completed an in-person competency check with the DON. On 05/10/23 medical staff not available in the facility completed an online mechanical lift training and policy review. On 05/10/23 medical staff not available in the facility completed a verbal competency check with the DON. On 05/10/23 maintenance staff completed an inspection of all mechanical lifts. On 05/10/23 medical staff were educated to only use the 600 pound lift for Resident #50. On 05/10/23 Resident #50's care plan was updated to indicate using only the 600 pound lift. On 05/10/23 weekly audits were initiated for 30 days to include monitoring of staff members following the mechanical lift policy and procedures. No evidence of any incorrect mechanical lift use was observed during audits completed on 05/11/23, 05/19/23, 05/24/23, 06/02/23, 06/07/23 and 06/13/23. There were no unsafe resident transfers from 05/10/23 to 06/14/23 (the time of the onsite complaint investigation). This deficiency represents non-compliance investigated under Complaint Number OH00143330 and OH00143300.

Based on observation, record review, review of manufacturer's guidelines for bed canes and beds and interview the facility failed to ensure equipment was used properly and within manufacturer's guidelines resulting in a fall with injury for Resident #21. This affected one resident (#21) of three residents reviewed for accidents. Actual Harm occurred to Resident #21 on 04/02/22 when she was using a bed cane for mobility which had a weight limit which Resident #21 exceeded resulting in the bed cane breaking and Resident #21 falling out of bed. The fall resulted in the resident being transferred to the emergency room due to uncontrolled bleeding of a leg wound sustained as a result of the fall which required stitches to the wound. Findings include: Review of Resident #21's medical record revealed diagnoses including acute and chronic [CONDITION(S)], [CONDITION(S)] status, hypertensive [CONDITION(S)], congestive heart failure, [CONDITION(S)], chronic obstructive pulmonary disease, [CONDITION(S)], and type 2 diabetes mellitus. A bed safety review, dated 02/25/22 revealed an assist bar or bed cane was on both sides of the bed to act as an enabler for turning and repositioning. The assessment indicated Resident #21 and her representative were educated on the use of the device as well as the risk and benefits. The assessment indicated Resident #21 weighed 339 pounds and bed assist rails were installed per manufacturer's guidelines. A care plan initiated 02/25/22 revealed Resident #21 was at risk for falls related to obesity and weakness with a goal not to sustain a major injury related to falls. Interventions included assessing risk for falls on admission, readmission, quarterly and as necessary. A fall risk assessment dated [DATE] revealed Resident #21 had no falls but continued to have potential risk. A post-fall evaluation dated 04/02/22 at 2:00 A.M. revealed as a result of an unwitnessed fall, a skin tear measuring two centimeters (cm) in length by one cm width was observed to the front of the resident's right lower leg. An on-call physician note dated 04/02/22 at 4:34 A.M. indicated the arm rest of the bed broke and Resident #21 rolled off the bed. A nursing note, dated 04/02/22 at 9:55 A.M. indicated pads under Resident #21 were soaked with copious amounts of dark red blood with some clotting observed. A bandage wrapped around the right lower extremity was saturated with blood. A gash approximately two inches was observed when the bandage was removed with dark red blood pouring out of wound. Direct pressure was applied to the site. Resident #21 reported the gash occurred when she fell out of the bed overnight when the enabler gave way. Emergency services were contacted and Resident #21 was sent to the hospital at 9:50 A.M. A nursing note, dated 04/02/22 at 2:08 P.M. indicated the hospital reported direct pressure was not effective in controlling the bleeding but the bleeding was able to be controlled with the use of epi. The wound was stitched. A nursing note dated 04/03/22 at 7:37 A.M. indicated Resident #21 had received six stitches in her right lower leg. On 04/18/22 at 12:40 P.M. interview with Resident #21 revealed the rails that were on her bed at the time she fell (out of bed) were only secured with thin zip lock ties and they broke. Resident #21 revealed she sustained an injury to her leg as a result of the fall which required stitches and caused her pain. On 04/18/22 at 2:10 P.M. interview with the Administrator verified Resident #21 sustained a fall from bed when the bed rail/cane that had been in place broke. On 04/18/22 at 2:24 P.M. observations of bed rail/cane used on another resident's bed with Maintenance Director #100 revealed the bed cane was attached to a board with bolts. The board was placed under the mattress and attached to the bed frame in various places with zip ties. Maintenance Director #100 revealed there was a 300 pound weight limit for use of the bed cane. On 04/18/22 at 2:30 P.M. review of information on the Stander Bed Cane with Maintenance Director #100 verified the cane supported weight up to 300 pounds. Maintenance Director #100 revealed he did not install the cane on Resident #21's bed. On 04/19/22 at 9:05 A.M. interview with Temporary Nurse Aide (TNA) #105 revealed Resident #21 had pulled herself over in bed using the left bed cane in order for TNA #105 to remove a bed pan from under her. TNA #105 stated she turned to take the bedpan to the bathroom to empty it and heard Resident #21 fall but did not see it happen. TNA #105 revealed she observed a zip tie on the floor after the fall but did not notice the condition of the bed cane. On 04/20/22 at 11:48 A.M. interview with the Director of Nursing (DON) revealed Resident #21 was using the [NAME] Medical Drive Bariatric 750 full electric bed for which the owner's manual was provided. Review of the [NAME] Medical Drive Bariatric 750 full electric bed revealed on page 6 the manual a warning that possible injury or death could occur if accessories were not provided by [NAME] medical by Drive. Page 7 indicated the only items which had been specified as part of the bed or that had been specified as compatible with the bed should be connected to it. Page 8 reaffirmed only compatible [NAME] Medical by Drive assist rails could be used on the bed. On 04/20/22 at 12:32 P.M. the DON was asked if the facility had a list of bed rails which were compatible with the [NAME] Medical Drive Bariatric 750 full electric bed. This information was requested again on 04/20/22 at 3:36 P.M. without additional information provided. On 04/20/22 at 3:36 P.M. interview with the Administrator revealed the day of the Resident #21's fall it was determined through inspection of the bed cane that it broke underneath where the rail was bolted to the board. The Administrator acknowledged the bed cane indicated it would support a weight of 300 pounds. A request was made for any information available indicating the Stander bed cane was compatible to be used on the [NAME] bed. No information was provided. This deficiency substantiates Complaint Number OH 646.

Based on observation, medical record review, witness statement review, personnel record review and interview, the facility failed to ensure the correct mechanical lift was utilized during a transfer resulting in a fall for Resident #3 and failed to implement fall interventions, as determined necessary by the care plan, for Resident #5. This affected two (Resident #3 and #5) of three residents reviewed for falls. The census was 67. Actual harm occurred when a sit-to-stand mechanical lift was used by one State tested Nurse Aide (STNA) instead of the care-planned and physician-ordered mechanical (Hoyer) lift by two staff members. Resident #3 was lowered to the floor from the sit-to-stand mechanical lift and was subsequently diagnosed with [REDACTED]. Findings include: 1. Review of the medical record for Resident #3 indicated an admission date of [DATE], and readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] indicated Resident #3 was severely cognitively impaired, had moderately impaired vision, usually understood verbal content, utilized a wheelchair for mobility and was totally dependent on two-staff members for physical assistance when transferring. Review of the fall care plan updated 11/04/19 indicated Resident #3 was at risk for falls related to diminished safety awareness, gait/balance problems, history of falls, incontinence, poor communication/comprehension and vision/hearing problems. An intervention included transfer via Hoyer mechanical lift with two staff. Review of the nurse's notes dated 07/24/20 indicated per interviews of staff and resident and thorough observation, Resident #3 was dependent on two staff and Hoyer lift for all transfers. Review of the August 2020 physician orders [REDACTED]. The order was initiated on 06/21/19. Review of the nurses note dated 08/08/20, timed 8:19 A.M., written by Licensed Practical Nurse (LPN) #5, indicated during transfer with Hoyer lift and two staff members, Resident #3 jerked her legs hitting her left knee on the lift. Resident #3 had complaint of pain to the left knee, ice applied and leg elevated. The nurse practitioner notified, and new order received to x-ray to left knee. Review of the nurses note dated 08/08/20 timed 10:33 A.M. indicated x-ray results received: distal femoral fracture. Resident #3 transferred to the hospital via ambulance. Review of the nurses note dated 08/08/20 timed 12:38 P.M. written by LPN #5 indicated clarification: staff unable to stop resident's leg from running into Hoyer lift bar. Immediate intervention was to educate staff via return demonstration of Hoyer lift transfer. Review of the witness statement dated 08/08/20 written by STNA #16 indicated Around 5:00 A.M. to 5:30 A.M., I went into (Resident #3's) room and started to get the resident ready for her shower. As I hooked her up to the sit-to-stand, me and another aide was moving her to the shower chair, and she began to pee, and her feet started to slide. I noticed her gown was slipping up towards her neck and I was worried she was going to choke. We let her down and her legs got caught under the sit-to-stand and I was trying to get them loose. We got her in the shower chair, and I gave her a shower and we put her back to bed. That's when I noticed her knee was red and swollen. Review of the hospital physician progress notes [REDACTED]. Upon review of the patient's medical records sent from the nursing home, the resident had an x-ray performed today at approximately 10:00 A.M., that showed an acute oblique distal femoral fracture with some mild diffuse soft tissue swelling. The resident does have tenderness starting at the mid-femoral shaft extending to the knee joint. Review of the hospital physician progress notes [REDACTED].#3 was brought to the hospital for pain in leg. After palpating both legs, it was discovered she had bilateral periprosthetic distal femur fractures. The resident had a complex medical history and did not do much ambulation. The resident was having significant pain with moving her for self-care. The resident continued to withdraw from pain to bilateral knee palpation. Review of the hospital physician progress notes [REDACTED].#3 was status [REDACTED]. Review of the nurse practitioner progress note dated 08/17/20 indicated Resident #3 was readmitted status [REDACTED]. Observation on 10/05/20 at 6:50 A.M. revealed Resident #3 was lying in bed, awake with the overbed light on above the resident's head. An attempt to interview the resident was unsuccessful, Resident #3 did not verbally respond. Interview on 10/05/20 at 3:25 P.M. with the Director of Nursing (DON) verified Resident #3 should have had a Hoyer lift transfer with two staff members instead of a sit-to-stand mechanical transfer with one staff member during the 08/08/20 fall. The other STNA (STNA #7) entered the room as Resident #3 was yelling on the floor. The DON verified Resident #3 fell due to STNA #16 using the incorrect mechanical lift and operating a mechanical lift alone resulting in the resident having bilateral femur fractures. Observation on 10/05/20 at 3:56 P.M. revealed Resident #3 sitting in her in room in a wheelchair with a Hoyer lift pad underneath her. When spoken to Resident #3 mouthed an unintelligable word. Interview on 10/05/20 at 4:25 P.M. with STNA #7 revealed she worked the night of 08/08/20 with STNA #16 and was planning on assisting with Resident #3's shower. STNA #7 verified Resident #3 required a Hoyer lift transfer with two staff members. STNA #7 was changing another resident and heard yelling. STNA #7 walked into Resident #3's room and STNA #16 had used a sit-to-stand lift on Resident #3 and the resident did not have an incontinence brief on. The resident had a bowel movement and urinated while hanging by the arms of the sit-to-stand lift; Resident #3 was not talking at all and eyes were closed. STNA #16 attempted to put the resident's legs on the sit-to-stand footrest however Resident #3's leg would not bend when attempting. The STNAs removed the resident from the sit-to-stand lift and lowered the resident to the floor. During an observation of a sit-to-stand mechanical lift on 10/05/20 at 4:30 P.M. STNA #7 demonstrated how Resident #3's knees were not pressed up against the padded knee rest and the resident's feet were not placed on the footrest but were in front of the footrests at the time of the 08/08/20 fall. Interview on 10/13/20 at 8:15 A.M. with the Administrator revealed when a resident was lowered to the floor, it was considered a fall. Review of STNA #16's personnel record indicated STNA #16 was terminated from employment on 08/10/20 due to not following a resident's plan of care. 2. Review of the medical record for Resident #5 indicated an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the nurses note dated 05/23/20 timed 9:53 A.M. indicated Resident #5's roommate came to the door yelling that the resident was on the floor and the nurse upon responding observed Resident #5 on the bathroom floor. Resident #5 stated she was trying to take herself to the bathroom. A new intervention included non-skid strips in front of toilet. Review of the interdisciplinary follow up note dated 05/26/20 indicated Resident #5 was self-transferring at the time of the fall due to poor safety awareness. The intervention after the fall was non-skid strips to floor in front of toilet. Review of the fall care plan revised on 10/05/20 indicated Resident #5 was at risk for falls related to [MEDICAL CONDITION], tremors, [MEDICAL CONDITIONS] (TIA), adverse side effects from her medications and exacerbation of signs and symptoms of her disease process, history of fracture of right hip and cognitive deficits. An intervention included: non-skid strips to floor in front of toilet instituted on 05/28/20. Observation on 10/05/20 at 6:52 A.M. revealed Resident #5 was sitting in a wheelchair in her room, dressed in street clothes and wearing glasses. There were no non-skid strips on the floor in front of the toilet in the resident's bathroom. Interview, during the observation, with Resident #5 provided inconsistent information. Observation on 10/06/20 at 8:00 A.M. revealed Resident #5 was lying in bed, feeding herself breakfast, wearing glasses. There were no non-skid strips on the floor in front of the toilet in the resident's bathroom. Interview, during the observation, with the Director of Nursing verified the care planned fall intervention of non-skid strips to be applied on the floor in front of the toilet were not in place. Review of the MDS 3.0 significant change assessment dated [DATE] indicated Resident #5 was moderately cognitively impaired and required extensive assistance of one staff member for transfers and toilet use. This deficiency substantiates Complaint Number OH 306 and OH 28.

Based on interview and record review, the facility failed to prevent willful resident to resident abuse resulting in physical harm. Actual Harm occurred when Resident #1 attacked Resident #77 and Resident #77 sustained a fractured vertebrae. This affected one (Resident #77) of three residents reviewed in two Self Reported Incident (SRI) reports. Findings include: Review of the medical record revealed Resident #77 was admitted to the facility with [DIAGNOSES REDACTED]. She had been living alone prior to the admission and was at the facility for therapy and treatment of [REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #77 had severe cognitive impairment, displayed other behavioral symptoms not directed toward others and rejected care. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 3.0 assessment dated [DATE] indicated Resident #1 had moderate cognitive impairment and no symptoms of [MEDICAL CONDITION] or behaviors. She required the extensive assistance of one for activities of daily living. Review of Resident #1's progress notes revealed after a fall on 01/19/18, Resident #1 displayed increased confusion, agitation and was verbally abusive to staff. The nurse practitioner ordered a urinalysis. On 01/19/18 at 2:14 P.M. the resident was very manic, refused care and told staff to get out. She was seen by the nurse practitioner. On 01/19/18 at 10:21 P.M. Resident #1 was anxious throughout the shift, walking without assistance and going into other residents' rooms. She began antibiotic treatment for [REDACTED].M. Resident #1 was witnessed lowering herself to the floor. She did not come into contact with any objects. She refused vital signs, was combative, swearing and swinging at staff. Vital signs and neurological checks would be completed as she allowed. On 01/23/18 at 8:30 A.M. Resident #1 was agitated and threatened a state tested nurse aide (STNA). The nurse attempted to calm her down but she screamed and balled her hand into a fist. The nurse practitioner was notified of the resident's behaviors and ordered an intramuscular anti-psychotic medication. The nurse noted that the injection was given with the assistance of three staff members. On 01/23/18 at 11:15 A.M. the STNA followed the resident with the wheelchair because she was screaming and refused assistance. When the nurse approached she threw her walker and sat hard into her wheelchair. She was sent to the hospital for evaluation and treatment. On 01/23/18 at 7:04 P.M. the family informed the facility Resident #1 was given an intramuscular medication to calm her down in the hospital. She had been in full restraints until the medication was effective and then went to a waist restraint. She would be returning to the facility. The laboratory work and the scans were all negative. Resident #1 returned to the facility on [DATE] and repeatedly pulled the call light out of the wall saying she was trying to call her son. Fifteen minute checks were put into place. On 01/24/18 at 7:57 A.M. it was noted Resident #1 had been up all shift, in and out of her room, moving everything around. Reality orientation was ineffective but she was redirected easily. On 01/24/18 at 2:24 P.M. she was sitting on the edge of her bed saying, Take me home. She continued on 15 minute checks. On 01/24/18 at 11:12 P.M. she was ordered an antibiotic for a urinary tract infection. The progress notes for 01/25/18 and 01/26/18 indicated she was pleasant and cooperative. On 01/26/18 at 3:28 P.M. the nurse practitioner changed the antibiotic to treat her urinary tract infection. Review of Resident #77's progress note authored by Registered Nurse (RN) #81 dated 01/27/18 at 3:40 A.M. indicated she was called to the area by staff. Resident #1 was being held by staff. She was kicking scratching, biting, pulling and pushing very aggressively with open and closed hand hits. Resident #77 was up in a wheelchair and had scratches on the left side of her face, bruising around the left eye and swelling of two areas on the right side of her head. For safety Resident #77 was moved to another area with one to one staff. At 3:45 A.M. one to one was provided and ice was applied to left eye and face and right side of head by two staff members. Resident #77 had her usual range of motion and no complaints of pain in her extremities. One to one was partially effective as Resident #77 was visibly shaken and having an anxiety attack. On 01/27/18 at 4:00 A.M. Resident #77 was transported to the hospital for evaluation and treatment. Review of Resident #77's progress note authored by Licensed Practical Nurse (LPN) #82 on 01/27/18 at 4:35 A.M. indicated STNA #83 yelled for her to come to the room. She noted Resident #77 on the floor and the roommate, Resident #1, was half on top of her holding both wrists. Resident #77's face had blood on the right side and red marks all over. Resident #1's hands were pried off pulled away from Resident #77. Resident #1 continued to fight, scratch, kick and pinch. LPN #82 yelled for STNA #84. STNA #84 got Resident #1 into the hall away from Resident #77. Resident #77 said Resident #1 came over to her bed, took her money, was choking her and then pulled her out of bed onto the floor and kept slapping her in the face. On 01/27/18 at 8:03 A.M. Resident #77 was admitted to the hospital with [REDACTED]. Review of Resident #1's progress note dated 01/27/18 at 4:24 A.M. indicated LPN #83 noted the incident with Resident #77 and added Resident #1 was yelling, She took my rent money. When the nurse told Resident #1 Resident #77 did not take her rent money, Resident #1 said, If she didn't then you did, and then lunged at the nurse. Resident #1 was kept in isolation, and was ordered a [MEDICAL CONDITION] medication until she was sent to the hospital. The hospital medicated her and returned her to the facility when one to one supervision was initiated and continued as of 01/31/18. On 01/31/18 at 11:15 A.M. Resident #1 was observed lying in her bed holding onto a laminated copy of the Lord's prayer. STNA #78 was sitting in a chair at the foot of her bed. The resident recited some of the Lord's prayer and said God was not ready for her yet. Interview with RN #81 on 01/31/18 at 8:30 A.M. said she was the supervisor the night of the incident. RN #81 said she was called to the unit on 01/27/18 around 3:30 A.M. because they needed all hands on deck. She arrived to a chaotic scene. Resident #1 was being held by staff, was verbally and physically abusive, and was kicking and biting. RN #81 asked what happened and was told the residents were checked 15-20 minutes prior and everything was calm. She said Resident #77 was seated in her wheelchair with bruises and scratches on her face. She said Resident #77 said she was in bed and Resident #1 accused her of stealing something, attacked her, hit her and dragged her out of bed. RN #81 assessed Resident #77 who had visible bruising around her eye and scratches. RN #81 said she did neuro checks and applied ice to the resident's eye, cheek and areas on her head. Because the resident was up in a wheelchair, she did not want to move her. She had difficulty trying to reassure the resident because she was panicked. The emergency squad was called for both residents, Resident #77 for the injuries and Resident #1 for uncontrolled behaviors. RN #81 said she interviewed staff who indicated everything was fine 15 minutes before. There was nothing that precipitated the event. Interview with the Director of Nursing (DON) and Regional Nurse #88 on 01/31/18 at 9:30 A.M. verified the incident that caused Resident #77's injury and indicated Resident #1 would remain on one to one supervision until another placement was found. They indicated they were surprised by the incident because she had not displayed any aggression toward another resident. This deficiency substantiates Master Complaint Number OH 975 and Complaint Number OH 922 and is an example of continued non-compliance from the annual survey dated 12/07/17.

Based on review of medical records, facility incident report, facility summary of investigation, staff statements, Emergency Medical Services (EMS) run report, emergency department report, facility dietary guidelines on mechanical soft diet textures with nectar thickened liquids, and staff and family interviews, the facility failed to provide adequate supervision during and after the dinner meal for Resident #96 who was on a mechanically altered diet with nectar thickened liquids to prevent choking. Resident #96 experienced actual harm when he began to choke after consuming a food item he should not have received (watermelon) during dinner requiring staff intervention to physically clear his mouth and airway. Immediate Jeopardy resulted when Resident #96 was returned to his room where he was later found unresponsive requiring cardiopulmonary resuscitation. Emergency medical services (EMS) arrived and were unable to establish a patent airway due to blockage by a plastic jelly packet. This affected one of three residents reviewed for choking. On [DATE] at 12:32 P.M., the administrator, director of nursing (DON), Regional Registered Nurse #22 and the Corporate Director of Operations were notified Immediate Jeopardy began on [DATE] at 5:25 P.M. when Resident #96 received watermelon contrary to physician orders for a mechanical soft diet with nectar thick liquids and began to choke requiring staff intervention to clear his mouth and airway. Resident #96 was returned to his room without adequate supervision or assessment of his status. Resident #96 became unresponsive when no staff were present in his room. The Immediate Jeopardy was removed on [DATE] at 4:00 P.M. when the facility implemented the following corrective actions. · On [DATE], the DON initiated in-service education for all staff related to condiment packets of any kind being prohibited in the building. All condiments would be served in multi-use containers. A nurse would be assigned to the dining room for the first twenty minutes of the meals to verify the correct diets were served as indicated in the physician orders. All staff were responsible to ensure appropriate diets were provided to residents. If staff observed residents chewing or putting non-food objects in their mouths, nursing was to be notified to implement interventions. This in-service education was completed for all staff on [DATE] at 4:00 P.M. · On [DATE], Regional Registered Nurse #22 initiated a search checking all resident rooms to ensure any packets of condiments were removed and discarded. The search was completed on [DATE] at 12:00 A.M. · On [DATE] through [DATE], the nursing staff completed daily audits of both dining rooms and room trays to ensure meals were served as indicated in the physician orders. · On [DATE], beginning with the breakfast meal, the DON initiated nursing staff supervision at each meal, three times daily. Nursing staff were required to monitor proper food diet/texture was being served by double checking each resident's meal tray with the meal ticket for accuracy prior to the meal being served to the resident. · On [DATE] at 5:20 P.M. and [DATE] at 1:26 P.M., observations of both dining areas revealed nursing personnel was in the dining room and meal tickets were being verified before residents were served. All residents were served the correct physician ordered diets. · On [DATE] between 2:00 P.M. and 4:08 P.M., interviews with Registered Nurse (RN) #4, State tested Nurse Aide (STNA) #8, RN #9, RN #16, Licensed Practical Nurse (LPN) #17, STNA #18, STNA #47, STNA #48, STNA #49, Activities Assistant #50, STNA #51, STNA #52, Speech and Language Therapist #53, LPN #54 and RN #55 revealed all staff were able to describe the new meal service plan that had been implemented. All staff verified they had been in-serviced regarding resident diets and food consistencies. Although the Immediate Jeopardy was removed, the facility remained out of compliance at severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy), as the facility was in the process of implementing their corrective actions and monitoring for effectiveness. Findings include: Review of Resident #96's medical record revealed the resident was admitted on [DATE] and was discharged home on [DATE]. Resident #96 was readmitted on [DATE]. Resident #96 had [DIAGNOSES REDACTED]. Resident #96 was a full code (full resuscitation in the event of absence of pulse and or respirations). Review of Resident #96's care plan revealed interventions dated [DATE] including assisting with meals as needed, diet as indicated in the physician orders including nectar thickened liquids and monitor the tolerance to the diet texture and make adjustments as needed. An intervention dated [DATE] indicated divided plate for all meals. Review of Resident #96 ' s physician orders revealed on order dated [DATE] for a divided plate for all meals and an order dated [DATE] for a mechanical soft diet with nectar thickened liquids and no added sugar or sugar substitute. Review of Resident #96's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment and required setup and supervision for eating. Review of Resident #96's progress notes dated [DATE] at 5:25 P.M. written by RN #14 revealed the resident was removed from the dining room after the resident coughed and then appeared to choke on watermelon. Resident #96's mouth was cleared of watermelon. Resident #96's pulse oximetry (blood oxygen level) was 89% (normal 92 to 100%) on room air and the resident was lethargic but arousable to name. Upon assessment, Resident #96 ' s lungs had crackles (abnormal lung sounds) anteriorly. At 5:30 P.M. the nursing assistants were checking on the resident every ten minutes and one nursing assistant stayed in the resident's room until 7:15 P.M. At 7:43 P.M. the progress notes indicated the resident was found unresponsive with no breathing or pulse. Cardiopulmonary resuscitation (CPR) was initiated at 7:20 P.M. and an automated external defibrillator (AED) was applied to the resident's chest with no shock advised after each cycle. The emergency medical squad was called and arrived at the facility. Resident #96 was transferred to the hospital. Review of the Emergency Medical Services (EMS) documentation dated [DATE] revealed emergency medical services (EMS) responded to a report at 7:31 P.M. of a patient in cardiac arrest. On arrival, staff was performing compressions without ventilations and an AED was applied which indicated no shock advised. CPR was paused and the patient was found to be pulseless and apneic (without breathing). EMS continued compressions and coached a staff member to provide bag mask ventilations while a monitor and defibrillator was applied. The initial rhythm was asystole (no heart rhythm) which continued for the duration of EMS care. Staff reported that the resident choked on food earlier in the day. During an intubation attempt (insertion of a tube into the mouth and then into the airway), a plastic object was visualized in the patient's airway, a jelly packet, one inch by one inch, in size. Review of the Emergency Department Report dated [DATE] at 8:22 P.M. indicated Resident #96 was brought into the emergency department during cardiac arrest. Resident #96 was transferred from a nursing home and reportedly choked while eating watermelon. Resident #96 became unresponsive, went into cardiac arrest and CPR was initiated. The EMS continued CPR and attempted to intubate the patient but found a plastic condiment packet obstructing the resident's airway. Resident #96 was asystole during the entire course for EMS which was approximately 35 minutes. Review of the facility Incident Report dated [DATE] at 5:10 P.M. indicated Resident #96 was eating watermelon at supper and began to vomit and cough up watermelon. Resident #96 cleared his airway with coughing. Around 5:15 P.M., Resident #96 was placed back in bed and around 7:20 P.M., the roommate came out to the doorway as staff were heading into the room and found the resident unresponsive. Resident #96 was a full code and CPR was initiated and EMS was called. At around 9:00 P.M., the hospital notified the facility Resident #96 had expired and a jelly packet was found in the resident's airway. Review of RN #14's statement dated [DATE] revealed she was called into the dining room by a STNA who indicated Resident #96 was vomiting. RN #14 observed chunks of watermelon on a towel on the resident's chest and the resident was removed from the dining room. Oxygen was applied for an oxygen saturation level of 88% on room air. The oxygen saturation level increased to 92% on 2.5 liters of oxygen per minute via nasal cannula. Resident #96's lungs were ragged then became better with crackles. STNA #23 remained at the resident's bedside until 7:15 P.M. RN #14 was called back into the room by an STNA at 7:20 P.M. Resident #96 was found unresponsive. Review of STNA #23's statement dated [DATE] revealed she was sitting with Resident #96 who had oxygen on. Resident #96 sounded raspy. STNA #23 reported off to the night STNA and told the nurse that he looked pale. No time was indicated. Review of STNA #25's statement dated [DATE] revealed Resident #96's roommate called her and another STNA at 7:15 P.M. to the room because Resident #96 was in distress, (this time varies from RN #14's statement of 7:20 P.M.). STNA #25 observed that Resident #96 was not breathing and she got the nurse (RN#14). Review of the dietary menu identified by the facility for [DATE] revealed the breakfast consisted of a cheese omelet, bacon, wheat toast, choice of juice, milk and coffee. The dinner meal on [DATE] consisted of a hamburger with lettuce, tomato and onion, fries, slaw and watermelon. Observation on [DATE] at 12:44 P.M. revealed there were 28 residents, four STNAs, the speech therapist and one cook in the dining room. The first two rows of tables had been served their food. There was no nurse in the dining room. The STNAs were observed obtaining the plated food from the cook and distributing the food to the residents. Interview on [DATE] at 12:28 P.M. with Dietary Staff #27 revealed the evening meal for Resident #96 on [DATE] should have been a mechanical soft hamburger with no lettuce, tomato or onion, three bean salad, mashed potatoes and thickened canned fruit. Dietary Staff #27 revealed the resident should not have been served watermelon. Review of the undated Dietary Thickened Liquids guidelines revealed to avoid juicy foods like watermelon, apples or oranges. Interview on [DATE] at 1:33 P.M. with LPN #15 revealed she was not in the facility when Resident #96 choked on food but revealed a jelly packet was found in the resident's airway by EMS when they arrived at the facility. LPN #15 indicated watermelon was not part of Resident #96's dietary recommendations. Interview on [DATE] at 1:37 P.M. with RN #16 revealed Resident #96's diet included mechanical soft with nectar thickened liquids and the resident could not have watermelon. Interview on [DATE] at 2:10 P.M. with Dietary Staff #19 revealed meals were cooked and then placed on the steam table. Meal cards indicated what diet residents were ordered. Mechanical soft diets included ground up meats and she would not give residents on nectar thickened liquids watermelon but fruits such as peaches or pears. Interview on [DATE] at 2:20 P.M. with Dietary Staff #20 revealed Resident #96 was seated next to the steam table with Resident #75 on [DATE] during the dinner meal. The watermelon was placed in bowls on a side table and the nursing assistants delivered the watermelon to the residents during the meal setup. Dietary Staff #20 said she was not aware who delivered the watermelon to Resident #96 but the resident's diet did not include watermelon. Interview on [DATE] at 2:26 P.M. with LPN #29 revealed the nurses were supposed to enter the dining room and make sure the residents were being served the right foods and beverages. LPN #29 indicated she was told she had to be in the dining room for the first 20 minutes. LPN #29 confirmed she was not in the dining room at the beginning of the lunch meal on [DATE] and when she had entered the dining room half the residents had been served. LPN #29 stated she did not realize the kitchen had started serving and the dietary staff should have waited until the nurse entered the room to serve the meal. Interview on [DATE] at 2:28 P.M. with Dietary Staff #21 revealed her role during dining was to assemble food for residents on room trays and to sometimes help the cook. Dietary Staff #21 said residents with mechanical soft nectar thickened liquid diets would not be served watermelon but they could have peaches or pears. Dietary Staff #21 stated prior to the choking incident on [DATE], dietary staff placed individual condiment packets like ketchup and/or jelly packets on the counter top for the STNAs to provide for resident use. Interview on [DATE] at 2:41 with RN #22 revealed the facility nurses performed cardiopulmonary resuscitation for Resident #96 until the ambulance arrived. The emergency technicians visualized a one inch by one inch jelly packet when attempting to intubate the resident. RN #22 said Resident #96 did not have access to jelly packets that day. Interview on [DATE] at 3:50 P.M. with STNA #23 revealed Resident #96 was eating dinner and a family member visiting another resident informed her Resident #96 was coughing and choking. STNA #23 asked Resident #96 if he was okay and the resident started coughing more. Resident #96 was gasping and mumbling. Staff placed oxygen on the resident and took him to his room. STNA #23 stayed with the resident until just after 7:00 P.M. (unable to give an exact time). STNA #23 indicated while she was in the room with Resident #96 he was coughing like he had a mucous type cough or something, she described his respiration as raspy. STNA #23 said she was to inform the nurse if Resident #96 had any breathing concerns. STNA #23 indicated the nurse came into the resident's room at approximately 5:45 P.M. and was informed of the resident's raspy breathing and cough at that time. STNA #23 checked on Resident #96 prior to exiting the building and his color was off, he looked grayish and he was no longer coughing sometime between 7:00 P.M. and 7:30 P.M. (unable to give an exact time). STNA #23 indicated prior to leaving the building she informed the nurse the resident looked gray and she should get in there. Another STNA did not replace STNA #23 in Resident #96's when she left but the night shift aide, STNA #25, was to perform frequent checks on the resident. Interview on [DATE] at 4:10 P.M. with RN #14 revealed Resident #96 choked on watermelon in the dining room. RN #14 indicated she put on gloves and removed the watermelon from the resident's mouth and airway. RN #14 indicated she assessed Resident #96 when placing him into bed and then again fifteen to twenty minutes later. RN #14 indicated she did not reassess the resident again until he was found with no pulse or respirations. RN #14 indicated she placed STNA #23 in Resident #96's room because she had 24 other residents to care for and Resident #96 was a fall risk. The nursing assistant was to prevent the resident from falling and to inform her if the resident was coughing or having breathing problems. Interview on [DATE] at 4:38 P.M. with STNA #25 revealed staff were seating residents in the dining room for dinner and setting up drinks and desserts when Resident #96 was observed to have a raspy cough and turning blue. STNA #25 said STNA #23 was with Resident #96 and she called for nursing staff. Facility staff performed the Heimlich maneuver and she assisted the nurse to perform a finger sweep and remove watermelon from the resident's mouth and airway. STNA #25 indicated she was the nursing assistant assigned to care for Resident #96 during the 3:00 P.M. to 11:00 P.M. shift. In addition to STNA #23 being in the room, STNA #25 was to perform frequent checks on the resident. STNA #23 said she did not remember much except the resident's breathing was raspy and his skin coloring was weird about five minutes before he was found unresponsive. STNA #25 indicated she informed the nurse of her observation and CPR was performed. Interview on [DATE] at 5:29 P.M. with Resident #75's son revealed his father dined at the same table as Resident #96 and he visited the facility six to seven nights per week to assist his father during meals. He indicated on [DATE] he arrived in the dining room and observed Resident #96 having breathing problems. He knew there was something wrong because Resident #96 was drooling, having difficulty breathing and was turning red. He notified the STNA that something was wrong with the resident. He said the facility performed a Heimlich maneuver on the resident, cleared the resident's airway and removed the resident from the dining room. He also said Resident #96 chewed on lids that were placed on cups and he would pick up anything and put it into his mouth. Interview on [DATE] at 9:04 A.M. with the DON revealed the facility retrieved the plastic object that occluded Resident #96's airway from the emergency department and determined the packet did not match any food packets that were in the facility. The DON revealed she felt the packet was in Resident #96's stomach and when he threw up the watermelon, the packet started to come up with the watermelon. Interview on [DATE] at 9:06 A.M. with Registered Dietician (RD) #45 revealed she spoke to Speech Therapist #46 for recommendations on food items for residents on mechanical soft with nectar thickened liquid diets. RD #45 indicated watermelon should not be served to residents on a mechanical soft nectar thickened liquid diet. Interview on [DATE] at 9:38 A.M. with Speech Therapist #46 revealed the recommendation for Resident #96 included a mechanical soft diet with nectar thickened liquids and the resident was to be supervised during meals. Watermelon was an inappropriate food item for a resident on a mechanical soft nectar thickened liquid diet because of the liquid in the watermelon. A follow up interview on [DATE] at 10:40 A.M. with the DON revealed the facility did not have evidence Resident #96 was checked or assessed by a nurse following the resident's initial assessment on [DATE] at 5:25 P.M. until he was found unresponsive at approximately 7:20 P.M. Interview on [DATE] at 2:58 P.M. with the Medical Director (MD) revealed he was informed Resident #96 had a choking episode and subsequently was found without a pulse or respirations. The MD said he was informed Resident #96 had some issue with food consistency at the time of the choking episode. He was also informed a jelly packet was found by the emergency department in Resident #96's airway and he said that a jelly packet would be difficult for anyone to swallow. Review of the facility Standard of Nursing Practices policy dated ,[DATE] revealed residents experiencing a change in condition that was deemed stable must be checked at least every 60 to 90 minutes.