Every finding on record at Triple Creek Retirement Community

Based on medical record review, staff interview, and physician interview, the facility failed to obtain weights in a timely manner to monitor a resident's need for medications as an intervention per physician orders. This affected one (#5) of three residents reviewed for medication administration and orders. The census was 48. Findings include:Record review for Resident #5 revealed the resident was admitted to the facility on [DATE], and discharged on 05/14/26, with diagnoses including achalasia of cardia, hypertension, chronic kidney disease, congestive heart failure, dysphagia, diabetes, lymphoma, osteoarthritis, and hypothyroidism. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had intact cognition and was assessed to require staff assistance for self-care activities and mobility.Review of Resident #5's After Visit Summary, dated 04/09/26, revealed the resident's prescription for torsemide, a diuretic, was changed and a new order was created for torsemide 10 milligrams (mg) as needed for edema with a weight gain of greater than three pounds in one day or 10 pounds in one week.Review of the recorded weights for Resident #5 revealed the resident was weighed on 04/10/26, but not weighed again until 04/16/26.Review of the medication administration record (MAR) for Resident #5 revealed torsemide was only administered to Resident #5 one day (04/13/26) between 04/10/26 and 04/16/26.Review of Resident #5's physician orders revealed an order dated 04/19/26 for the resident to be weighed daily to determine if the resident should be given as need torsemide based on the guidelines of the order for a weight gain of greater than three pounds in one day or 10 pounds in one week.Interview with the Director of Nursing (DON) on 06/18/26 at 11:32 A.M. confirmed Resident #5's weights were not taken between 04/10/26 and 04/16/26. The DON stated she believed the resident's weights were not completed because the admitting nurse omitted an order for daily weights due to them not being explicitly requested in the After Visit Summary dated 04/09/26. The DON stated a call was placed to Resident #5's cardiologist to clarify the order on 04/16/26, which was when the order was affirmed by the physician, and the daily weight order was added to the resident's medical record system.Interview with Physician #900 confirmed in order to properly follow Resident #5's order for torsemide as prescribed on 04/09/26, the resident's weight should have been taken daily beginning on 04/10/26.This deficiency represents non-compliance related to Complaint Number 3016809.

Based on record review, observation, staff interview, and policy review, the facility failed to ensure proper personal protective equipment (PPE) was worn while providing care and services for a resident on Enhanced Barrier Precautions (EBP). This affected one (Resident #29) of three residents reviewed for infection control. The facility census was 45. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including toxic encephalopathy, Parkinson's disease, and gastrostomy status. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #29 was moderately cognitively impaired, was dependent on staff for toileting and lower body dressing and occasionally incontinent of urine and frequently incontinent of bowels. Review of the physician orders revealed Resident #29 had an active order dated 02/24/26 for staff to use EBP during high-contact care activities. Observations on 03/24/26 from 10:15 A.M. to 10:28 A.M., revealed Certified Nursing Assistant (CAN) #09 was in Resident #29's room with the door shut. CNA #09 was observed exiting and reentering the room without a gown on several occasions throughout the observation. Resident #29 had a sign on his door stating that he was on EBP and there was not a supply of PPE near his room. During an interview on 03/24/26 at 10:29 A.M. with Licensed Practical Nurse #17 revealed that CNA #09 was assisting Resident #29 with toileting and getting the resident dressed. Observation on 03/24/26 at 10:31 A.M. revealed CTNA #09 in Resident #29's room changing his bed sheets without a gown. A clear trash bag was observed in the room with discarded products. There were no gowns observed in the trash bag. During an interview on 03/24/26 at 10:32 A.M., CNA #09 verified that she was assisting Resident #29 with perineal care, toileting, and getting dressed. CNA #09 verified that Resident #29 was on EBP, there was not a supply of PPE near his room and that she did not wear a gown while providing personal care. Review of the active care plan revealed Resident #29 required EBP during high-contact care related to the presence of a feeding tube. Interventions included utilizing gowns and gloves per EBP policy during high contact activity of daily living (ADL) care (e.g. dressing, showering/bathing, hygiene, and toileting/changing briefs) and during linen changes. Review of the facility policy titled Enhanced Barrier Precautions (EBP) Standard Operating Procedure dated 12/3/25, revealed that at minimum, staff shall wear gloves and gowns during high contact care activities including ADL care, toileting, and showers.

Based on record review, interview, and facility document review the facility failed to ensure residents were free of significant medication errors for four (Residents #46, #103, #107, and #199) of four sampled residents reviewed for medication errors. The facility census was 50.Findings included: 1. Review of Resident Face Sheet revealed the facility admitted Resident #199 on 02/08/2025. The resident had a medical history that included diagnoses of cellulitis of the right and left lower limbs and methicillin-resistant Staphylococcus aureus (MRSA) infection. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/13/2025, revealed Resident #199 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. The MDS indicated Resident #199 did not reject care during the assessment's lookback period. The MDS revealed the resident had intravenous (IV) access on admission and while a resident. The MDS indicated Resident #199 admitted from a short-term general hospital. Review of Resident #199's Care Plan History, included a problem statement dated 02/19/2025, that indicated the resident required enhanced barrier precautions (EBP) during high-contact care related to the presence of a wound with dressing changes. Interventions directed staff to observe for and report any new or worsened signs/symptoms of infection. Review of Resident #199's Out-patient antibiotic therapy ([NAME])/Antibiotic Infusion orders, dated 02/07/2025, indicated the resident was to receive IV meropenem (an antibiotic) 1 gram (g) every eight hours and linezolid (an antibiotic), 600 milligrams (mg) by mouth every 12 hours, to complete 02/21/2025. The [NAME]/Antibiotic Infusion orders, indicated Resident #199 had bilateral leg wounds with a polymicrobial infection including MRSA infection. Review of Resident #199's View Prescription Order, received 02/09/2025 and started 02/10/2025, revealed a written physician's order for meropenem 1 g IV every eight hours, first administration time 12:00 A.M. Review of Resident #199's Physician Order Report, dated from 02/01/2025 through 07/02/2025, included an order for meropenem 1 g IV every eight hours at 12:00 A.M., 8:00 A.M., and 4:00 P.M., started on 02/10/2025. The Physician Order Report included an order for linezolid 600 mg by mouth every 12 hours for 14 days, started on 02/09/2025. Review of Resident #199's 02/2025 Medication Administration History revealed meropenem was not administered as scheduled on 02/10/2025 at 12:00 A.M. or 8:00 A.M. The Medication Administration History revealed staff documented that they administered the meropenem late on 02/10/2025 at 12:57 P.M. Further review revealed linezolid was not administered as scheduled on 02/09/2025 and 02/10/2025 from 7:00 A.M. to 11:00 A.M. The Medication Administration History revealed staff documented that they administered linezolid late on 02/10/2025 at 12:57 P.M. During an interview on 07/05/2025 at 12:37 P.M., Family Member #4, Resident #199's family member, stated Resident #199 was admitted to the facility to receive intravenous medications, but the antibiotics did not get started immediately after admission to the facility. During an interview on 07/08/2025 at 1:32 P.M., Licensed Practical Nurse (LPN) #5 indicated she could not recall transcribing the resident's admission orders and was unsure why Resident #199's antibiotic orders were not started immediately as ordered. During an interview on 07/08/2025 at 2:06 P.M., the Medical Director (MD) stated he was unaware that Resident #199's IV antibiotics were not started on admission but two days after admission. The MD stated he expected medications to be available to be administered as ordered and to be notified if medications could not be administered so the orders could be potentially modified or to provide further instructions, because when antibiotics were missed it resulted in a delay in treatment. During an interview on 07/09/2025 at 3:56 P.M., the Pharmacist revealed medication orders were received from the facility through an electronic medical record submission. The Pharmacist stated the pharmacy relied on the facility to transcribe all orders from a hospital discharge into the medical record. The Pharmacist stated the cut-off time for filling new admission orders for the standard delivery was 7:00 P.M.; however, the facility could contact the pharmacy to request medication be sent stat ( immediately, at once) or drop shipment which would allow medication to be sent in as little as four hours. The Pharmacist stated anytime a nurse did not have a medication that was needed to be administered, they should contact the pharmacy to request a delivery time and request either a drop shipment or stat delivery of the item. The Pharmacist stated the pharmacy received the IV meropenem order on 02/09/2025 at 3:40 P.M., it was requested to be delivered stat, and it was received in the facility on 02/09/2025 at 10:00 P.M. During an interview on 07/10/2025 at 3:00 P.M., the Assistant Director of Health Services (ADHS) stated she expected residents to receive their medication when it was delivered and not have to wait until the next day. The ADHS stated she expected nurses to call the pharmacy to drop-ship any medications they did not have. On 07/11/2025 at 7:28 A.M. the Director of Health Services (DHS) stated when they received orders for a resident, they sometimes received an after-visit summary (AVS), a discharge summary, and/or continuation of care documents. The DHS stated staff entered the orders, tried to have another nurse look at the order if it was a high risk medication, called the doctor to confirm the orders and make any changes, faxed the orders to the pharmacy, called the pharmacy to confirm the orders were received, and had the medications drop-shipped to the facility if the medications were not available in the facility's backup medication inventory. The DHS stated nurses had a list of the available medications. The DHS stated normally antibiotics were started within 24 hours, and staff confirmed the hospital had given the resident a dose before discharge. The DHS stated they would call the doctor to see what they could do if they were not able to get the resident's medications right away. The DHS stated they should have gotten an order from the doctor as to when they wanted them to start medications for Resident #199. 2. Review of Resident Face Sheet revealed the facility admitted Resident #107 on 03/20/2025 at 6:55 P.M. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of cellulitis of the right upper and lower limb, gangrene, Group B Streptococcus (a bacteria), aftercare following a surgical amputation, and acquired absence of the right finger. Review of the admission Minimum Data Set (MDS), with an admission Reference Date (ARD) of 03/24/2025, revealed Resident #107 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. The MDS also indicated that the resident did not reject care during the assessment's lookback period. The MDS revealed the resident received intravenous (IV) medications while a resident. The MDS indicated Resident #107 admitted from a short-term general hospital. Review of Resident #107's Care Plan History, included a problem statement dated 03/24/2025, that indicated the resident required enhanced barrier precautions (EBP) during high-contact care related to the presence of a wound with dressing changes and a central line. Interventions directed staff to observe for and report any new or worsened signs/symptoms of infection. Review of the physician's ID [Infectious Disease] progress note, dated 03/20/2025 and electronically signed on 03/20/2025 at 9:26 A.M., indicated Resident #107 had a right index finger infection, bacteremia, and a diabetic foot infection. The ID progress note indicated the illness posed a threat to life or bodily function. The ID progress note indicated recommendations included: continue daptomycin (an IV antibiotic) 6 mg/kg (milligrams/kilogram) IV every 24 hours; continue meropenem (an IV antibiotic) 1 g (gram) IV every 12 hours in house and at discharge transition to ertapenem 1 g IV every 24 hours; and continue daptomycin and ertapenem four weeks from the last surgical debridement. Review of Resident #107's Physician Discharge Summary, dated 03/20/2025 at 10:52 A.M., indicated a discharge diagnosis of gangrene of the right hand. The Physician Discharge Summary indicated, Start taking these medications, and included daptomycin 400 mg IV daily; ertapenem 1 g every 24 hours; and 5,000 units of heparin subcutaneously every 12 hours. Review of Resident #107's hospital Discharge Summary, dated 03/20/2025 at 4:20 P.M., included discharge instructions dated 03/19/2025 at 2:58 P.M. that revealed a discharge medication list that included doxycycline 100 mg twice daily; ertapenem 1 g every 24 hours; and heparin 5000 units/ml subcutaneously every 12 hours. The Discharge Summary did not include instructions to start daptomycin. Review of Resident #107's Progress Notes included an IDT [Interdisciplinary Team] Infection note, dated 03/20/205 at 10:56 P.M., written by the Director of Health Services (DHS), that indicated Resident #107 admitted to the facility with an amputated right finger related to gangrene and bacteremia. The note indicated Resident #107 was on IV ertapenem and received doxycycline by mouth. The note revealed the resident was being followed by an infectious disease provider. Resident #107's Physician Order Report, for the timeframe from 03/20/2025 through 04/04/2025, included orders for:- Doxycycline monohydrate (an antibiotic),100 mg capsule twice a day for cellulitis, started and ended on 03/21/2025.- Doxycycline monohydrate 100 mg capsule twice a day for cellulitis, started on 03/22/2025.- Ertapenem (an injectable antibiotic) 1 g IV for cellulitis, started and ended on 03/21/2025.- Ertapenem 1 g IV once a day for cellulitis, started on 03/22/2025.- Heparin, 5,000 unit/ml (milliliter) injected twice a day for deep vein thrombosis (DVT) prevention, started and ended on 03/21/2025.- Heparin, 5,000 unit/ml injected twice a day for deep vein thrombosis (DVT) prevention, started on 03/22/2025. - Micafungin (an antifungal medication), 100 mg IV once a day, started on 03/27/2025.The Physician Order Report did not include an order for daptomycin. Review of Resident #107's 03/2025 Medication Administration History revealed staff documented that Resident #107 received initial doses of heparin, doxycycline monohydrate, and IV ertapenem on 03/22/2025. The Medication Administration History revealed staff documented that heparin and doxycycline monohydrate were not available on 03/21/2025. The Medication Administration History did not include the transcription of an order for daptomycin. During an interview on 07/07/2025 at 1:26 P.M., the Assistant Director of Health Services (ADHS) reviewed Resident #107's discharge summary and verified the resident should have started daptomycin IV. The ADHS reviewed Resident #107's orders and stated it appeared the order was omitted. The ADHS stated orders were entered from the discharge summary and verified by the provider. During a follow-up interview on 07/08/2025 at 9:55 A.M., the ADHS stated she had reviewed Resident #107's medical chart and the staff entered orders from an after-visit summary (AVS) record when Resident #107 was admitted , which did not include daptomycin. The ADHS stated the AVS was completed after the discharge summary and infection disease note, so there was no need to contact a provider to question it. During an interview on 07/08/2025 at 10:36 A.M., the Infectious Disease (ID) Nurse Practice Manager reviewed Resident #107's medical record and stated the ID provider cared for the resident during their hospital admission from 03/11/2025 to 03/20/2025. The ID Nurse Practice Manager stated the ID provider wrote orders for Resident #107 to discharge to the skilled nursing facility (SNF) on daptomycin and ertapenem daily until 04/15/2025. The ID Nurse Practice Manager stated that discharge orders were inadvertently cancelled then immediately reinstated to continue at discharge. The ID Nurse Practice Manager stated she did not know if the provider who dictated the discharge summary missed the daptomycin order but included the ertapenem order. The ID Nurse Practice Manager stated she did not see where the ID provider changed Resident #107's order from daptomycin to doxycycline. The ID Nurse Practice Manager stated Resident #107 was seen in the office for a follow-up visit on 04/03/2025, and the provider was unaware the resident was not receiving both daptomycin and ertapenem and was unaware of the addition of micafungin. The ID Nurse Practice Manager stated the ID provider did not dictate the discharge summary and the daptomycin could have possibly been left off the summary when it was transcribed by a hospitalist. The ID Nurse Practice Manager stated the facility should have reconciled the orders for all documents upon admission, Resident #107 was supposed to receive the medications for their serious infection, and she considered not receiving an IV medication a major medication error. During an interview on 07/08/2025 at 2:06 P.M., the Medical Director (MD) stated he expected medications to be available to be administered as ordered. The MD stated he expected to be notified if medications could not be administered so the orders could be potentially modified or to provide further instructions, because when antibiotics were missed it resulted in a delay in treatment. During an interview on 07/08/2025 at 4:16 P.M., Licensed Practical Nurse (LPN) #7 indicated she only worked at the facility about one month, never learned to put in orders, so she did not think she was given Resident #107's admission packet with orders to enter but thought an administrative nurse entered the orders. LPN #7 stated she was told Resident #107's orders were in the electronic medical record, and she was told to verify the orders with the on-call provider. LPN #7 stated she did not need the paperwork to verify what was in the electronic medical record with the provider or to get medications from the pharmacy. LPN #7 stated because she never received the paperwork, she was unsure of Resident #107's orders or what was transcribed on admission. During an interview on 07/09/2025 at 3:56 P.M., the Pharmacist revealed medication orders were received from the facility through an electronic medical record submission. The Pharmacist stated the pharmacy relied on the facility to transcribe all orders from a hospital discharge into the medical record. The Pharmacist stated the cut-off time for filling new admission orders for the standard delivery was 7:00 P.M.; however, the facility could contact the pharmacy to request medication be sent stat immediately, at once) or drop shipment which would allow medication to be sent in as little as four hours. The Pharmacist stated anytime a nurse did not have a medication that was needed to be administered, they should contact the pharmacy to request a delivery time and request either a drop shipment or stat delivery of the item. The Pharmacist stated the pharmacy received the order for the ertapenem on 03/20/2025, the medication was dispensed by the pharmacy on 03/21/2025, and the medication was delivered as a routine order on 03/22/2025 at 5:12 A.M. The Pharmacist stated Resident #107's medications were not requested to be delivered stat or by drop-shipment services upon the resident's admission. During an interview on 07/10/2025 at 3:00 P.M., the ADHS stated it was the responsibility of the admitting nurses to ensure that reconciliation of the resident's medications was accurate, especially if there were differences between the AVS, continuity of care documents, and/or discharge summary. The ADHS stated a nurses should contact the doctor to confirm orders were correct. The ADHS stated Resident #107 should have received their first dose of medication the following day after admission on [DATE]. The ADHS stated doxycycline was prescribed to be given twice per day, and because the resident was admitted at 6:00 P.M., she would have expected Resident #107 to receive the first dose on the night shift on the day of admission. The ADHS stated if the facility did not have the medication available, then they should have obtained it from their backup medication inventory system. On 07/11/2025 at 7:28 A.M., the DHS stated when they received orders for a resident, they sometimes received an AVS, a discharge summary, and/or continuation of care documents. The DHS stated staff entered the orders, tried to have another nurse look at the order if it was a high risk medication, called the doctor to confirm the orders and make any changes, faxed the orders to the pharmacy, called the pharmacy to confirm the orders were received, and had the medications drop-shipped to the facility if the medications were not available in the facility's backup medication inventory. The DHS stated nurses had a list of the available medications. The DHS stated normally antibiotics were started within 24 hours, and they would confirm the hospital had given the resident a dose before discharge. The DHS stated the doctor was called if the facility could not get resident medications right away. The DHS stated anticoagulants were available in the backup medication inventory including heparin and Eliquis, and she expected them to be administered as ordered. The DHS stated she expected any resident to receive their insulin as ordered as a stock of insulin including Lantus, Novolog, and Humalog were in the backup medication inventory. The DHS stated Resident #107 had several antibiotics, including two IV antibiotics and one to be taken by mouth, ordered that needed to be clarified to ensure the resident received the correct one. The DHS stated she called the hospital and spoke with a doctor about Resident #107's antibiotics, and she stated she wrote the clarification in the IDT notes. The DHS stated Resident #107 was admitted with orders for heparin, doxycycline, and ertapenem that should have been administered and the doctor notified if they were not available. 3. Review of Resident Face Sheet revealed the facility admitted Resident #46 on 04/12/2025. The resident had a medical history that included diagnoses of aftercare following surgery for neoplasm, acute respiratory failure with hypoxia, pneumonia due to Pseudomonas (a bacteria), pulmonary fibrosis, interstitial lung disease, systemic stenosis with lung involvement, malignant neoplasm of upper lobe, left bronchus, or lung, and pulmonary hypertension. Review of the 5-day Minimum Data Set (MDS) with an admission Reference Date (ARD) of 04/17/2025 revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident had moderate cognitive impairment. The MDS also indicated Resident #107 did not reject care during the assessment's lookback period. The MDS revealed the resident received intravenous (IV) medications while a resident. The MDS indicated Resident #107 admitted from a short-term general hospital. Review of Resident #46's Care Plan History, included a problem statement dated 04/14/2025, that indicated the resident required IV medications related to pneumonia. Interventions directed staff to administer IV medications as ordered. Review of Resident #46's hospital Inpatient Discharge Summary, dated 04/12/2025, indicated the resident's discharge medications included a new prescription for cefepime (an antibiotic), 2 grams (g) IV every eight hours for four days. The Inpatient Discharge Summary indicated Resident #46 was admitted to the hospital after hypoxia (low oxygen) likely due to pneumonia following a left upper lobe lung wedge resection. Review of Resident #46's Physician Order Report, dated from 04/01/2025 through 07/01/2025, included an order for cefepime, 2 g IV every eight hours for four days, started on 04/12/2025 and ended on 04/15/2025. Review of Resident #46's 04/2025 Medication Administration History, revealed staff documented that they administered cefepime 2 g on 04/13/2025 at 4:00 P.M., and the medication was discontinued after the resident received six doses. The Medication Administration History revealed staff documented that cefepime was awaiting on 04/12/2025 at 10:17 P.M.; none on 04/13/2025 at 3:04 A.M., and drug/item unavailable on 04/13/2025 at 12:04 P.M. During an interview on 07/01/2025 at 10:50 A.M., Resident #46 stated they did not get their IV antibiotics on several occasions. During an interview on 07/01/2025 at 12:09 P.M., Family Member #8, Resident #46's family member, revealed when Resident #46 first arrived at the facility they had to wait a day or so to get most of their medications. Family Member #8 stated they were at the facility almost daily and Resident #46 was upset several times that medications were not provided as ordered, and the resident was told the medications could not be found or the facility did not have them. During an interview on 07/01/2025 at 3:04 P.M., Registered Nurse (RN) #9 stated nurses were to enter all medications into the medical record upon admission if the nurse management team had left the facility for the day. RN #9 stated after the orders were entered in the electronic record the pharmacy was immediately notified to ship the medications to the facility. RN #9 stated some IV medications were available to be used from the facility's backup medication inventory system, but some had to be shipped from the pharmacy. RN #9 indicated she could not recall caring for Resident #46; however, she documented the medication was unavailable then the medication was not available from the backup system and had not arrived from the pharmacy. RN #9 stated she did not contact the pharmacy to find out when the medication would arrive or contact the medical provider that the medication was unavailable to administer on 04/13/2025 at 4:00 A.M. because she thought the medication would arrive later that day. During an interview on 07/01/2025 at 3:36 P.M., LPN #5 stated she occasionally admitted residents to the facility and had been trained to enter orders for new admissions from the discharge summary into the electronic medical record, and the orders were sent electronically to the pharmacy. LPN #5 stated if a medication was not available, she contacted the pharmacy to see if it could be pulled from the backup medication inventory system. LPN #5 stated some IV medications were available in the backup system and some had to be shipped to the facility. LPN #5 stated she was on duty when Resident #46 was to receive the IV cefepime on 04/13/2025 at 8:00 A.M., but the medication was unavailable. LPN #5 stated she did not recall contacting the pharmacy to have the medication drop-shipped or to determine why the medication had not arrived as she thought it had been ordered and would arrive later that day. LPN #5 stated she did not recall contacting the provider about the antibiotic's unavailability because she thought it would start later that day. During an interview on 07/01/2025 at 3:58 P.M., LPN #10 revealed she was on duty on 04/12/2025 when Resident #46's 8:00 P.M. dose of IV cefepime was due; however, it had not arrived from the pharmacy. LPN #10 revealed she did not contact the pharmacy or the medical provider to notify them the medication was unavailable to be administered because she thought the medication would arrive the next day for administration. During an interview on 07/02/2025 at 9:25 A.M., the Director of Assisted Living (DAL) stated she was on duty on 04/12/2025 and assisted the skilled nursing facility side by entering Resident #46's pending orders, the orders entered from the discharge summary prior to the orders being verified by the facility admitting nurse with the provider, into the electronic medical record. The DAL stated depending on the time a resident arrived medications may need to be pulled from the backup system, drop-shipped from another pharmacy within two hours, or sent on the routine nightly delivery from the pharmacy. The DAL stated anytime a medication was not available nurses were to call the pharmacy and notify the physician of the unavailability of the medication unless the medication arrived before the end of the medication administration pass. The DAL stated unless specified to be daily or instructed not to be started immediately on admission all antibiotics were started immediately within a couple of hours after the resident arrived at the facility. The DAL stated an RN must start the first dose of IV medications; however, there was always an RN available in the building to start the medication for the resident. During an interview on 07/09/2025 at 3:56 P.M., the Pharmacist revealed medication orders were received from the facility through an electronic medical record submission. The Pharmacist stated the pharmacy relied on the facility to transcribe all orders from a hospital discharge into the medical record. The Pharmacist stated the cut-off time for filling new admission orders for the standard delivery was 7:00 PM; however, the facility could contact the pharmacy to request medication be sent stat ( immediately, at once) or drop shipment which would allow medication to be sent in as little as four hours. The Pharmacist stated anytime a nurse did not have a medication that was needed to be administered, they should contact the pharmacy to request a delivery time and request either a drop shipment or stat delivery of the item. He stated the pharmacy received the order for cefepime on 04/12/2025 at 6:26 PM, the cefepime was dispensed on 04/12/2025, and it was delivered to the facility on [DATE] at 1:59 A.M. During an interview on 07/10/2025 at 3:00 P.M., the Assistant Director of Health Services (ADHS) stated she expected a nurse to call the pharmacy to have any medications they did not have drop-shipped. The ADHS stated it was the nurses' responsibility to ensure reconciliation of residents' medications. On 07/11/2025 at 7:28 A.M., the Director of Health Services (DHS) stated when they received orders for a resident, they sometimes received an after-visit summary (AVS), a discharge summary, and/or continuation of care documents. The DHS stated staff entered the orders, tried to have another nurse look at the order if it was a high risk medication, called the doctor to confirm the orders and make any changes, faxed the orders to the pharmacy, called the pharmacy to confirm the orders were received, and had the medications drop-shipped to the facility if the medications were not available in the facility's backup medication inventory. The DHS stated nurses had a list of the available medications. The DHS stated normally antibiotics were started within 24 hours, and they would confirm the hospital had given the resident a dose before discharge. The DHS stated the doctor was called if the facility could not get resident medications right away. 4. Review of Resident Face Sheet revealed the facility admitted Resident #103 on 06/23/2025. The resident had a medical history that included diagnoses of encephalopathy, pneumonia due to methicillin susceptible Staphylococcus aureus (a bacteria) (MRSA), coronary artery bypass graft (CABG), acute pulmonary insufficiency following thoracic surgery, acute posthemorrhagic anemia, atrial fibrillation, and diabetes mellitus type 2. Review of the admission Minimum Data Set (MDS), with an admission Reference Date (ARD) of 06/30/2025, revealed Resident #103 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. The MDS also indicated Resident #103 did not reject care during the assessment's lookback period. The MDS revealed the resident received insulin. The MDS indicated Resident #103 was admitted from a short-term general hospital. Review of Resident #103's Care Plan History, included a problem statement started 06/30/2025, that indicated the resident was at risk for excessive bleeding and bruising related to medications. Interventions directed staff to administer medications per physician's orders; obtain laboratory specimens as ordered and notify the provider of abnormal results; and to notify the provider of abnormal bruising or bleeding. Review of Resident #103's Care Plan History, included a problem statement started 07/07/2025, that indicated the resident was at risk for hypo/hyperglycemia related to diabetes mellitus. Interventions directed staff to provide medications and to monitor blood glucose levels per orders. Review of Resident #103's Cardiothoracic Surgery Discharge Summary, dated 06/23/2025, indicated, Continue these medications which have changed and included Eliquis (used to prevent clots), 2.5 milligrams (mg) two times daily for 30 days due to a blockage of a blood vessel to the lung by a particle; insulin lispro (a rapid-acting insulin) 2 units under the skin three times daily before meals; and insulin aspart (a rapid-acting insulin) according to a sliding scale (a chart of insulin dosages based on blood glucose level levels). Review of Resident #103's 06/2025 Medication Administration History, dated 06/2025 revealed the following:- A transcription of an order for insulin lispro to be administered per a sliding scale before meals, started on 06/24/2025. The Medication Administration History revealed staff documented that on 06/24/2025 for the timeframe from 6:30 through 9:00 A.M. the residents blood sugar level was 568 mg/dL (milligrams per deciliter) and for the timeframe from 10:00 A.M. through 12:30 P.M. the residents blood sugar level was 212 mg/dL. The sliding scale revealed that if the resident blood sugar level was greater than 400, they were to call the medical doctor and if the resident's blood sugar was 181 to 220 to administer 6 units of the insulin. The Medication Administration History revealed staff documented that the first dose of sliding scale lispro was administered on 06/24/2025 for the timeframe from 3:30 P.M. to 6:30 P.M. - A transcription of an order for insulin lispro, 2 units subcutaneously before meals with a blood glucose level greater than 99 mg/dL, started on 06/24/2025. The Medication Administration History revealed staff documented that on 06/24/2025 for the timeframe from 6:30 through 9:00 A.M. the residents blood sugar level was 568 mg/dL and for the timeframe from 10:00 A.M. through 12:30 P.M. the residents blood sugar level was 212 mg/dL. The Medication Administration History revealed staff documented that the first dose of lispro was administered on 06/24/2025 for the timeframe from 3:30 P.M. to 6:30 P.M. - A transcription of an order for Semglee (insulin glargine, a long-acting insulin) 40 units at bedtime, started on 06/23/2025. The Medication Administration History revealed staff documented that the first dose of Semglee was administered on 06/24/2025.The Medication Administration History revealed no transcription of an order for Eliquis. An observation on 07/08/2025 at 8:58 A.M. revealed Resident #103 was delivered a breakfast meal tray including apple juice, pancakes, and bacon. An observation on 07/08/2025 at 9:10 A.M. revealed Resident #103 completed eating the entire breakfast meal and pushed the overhead table with the meal tray away from their bed. An observation on 07/08/2025 at 9:28 A.M. revealed a nurse entered the room with a cup of pills and vital sign equipment. The observation revealed Resident #103's blood glucose level reading was 121 mg/dL and insulin was administered to the resident's right upper quadrant of the abdomen. During an interview on 07/08/2025 at 9:38 A.M., Licensed Practical Nurse (LPN) #14 stated she had been educated to obtain blood glucose level readings prior to the resident eating a meal, and she should have taken Resident #103's blood glucose level reading and provided the resident with their insulin prior to their meal that morning. During an interview on 07/08/2025 at 2:06 P.M., the Medical Director (MD) stated resident blood glucose levels should be obtained before meals. During an interview on 07/09/2025 at 3:56 P.M., the Pharmacist revealed medication orders were received from the facility through an electronic medical record submission. The Pharmacist stated the

Based on record review, interview, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was completed for one (Resident #11) of one resident reviewed as part of the resident assessment task. The facility census was 50.Findings included:Review of Resident Face Sheet indicated the facility originally admitted Resident #11 on 02/24/2021 and most recently readmitted the resident on 08/05/2024.Review of Resident #11's MDS 3.0 Resident Assessments revealed a quarterly MDS with an ARD of 01/14/2025 and an annual MDS with an ARD of 06/12/2025 were completed; however, there was no indication any additional MDS assessments were completed between 01/14/2025 and 06/12/2025. During an interview on 07/03/2025 at 1:02 P.M., the MDS Coordinator stated she was responsible for completing all MDS assessments. She stated quarterly MDS assessments should be completed every three months. The MDS Coordinator stated that Resident #11 was not out of the facility when their quarterly MDS was due. She stated Resident #11's should have had a quarterly MDS completed around 04/15/2025. The MDS Coordinator confirmed Resident #11 did not have a quarterly assessment completed in 04/2025, but she did not know why. She stated it was important to complete MDS assessments accurately and timely to get a clear picture of what was going on with a resident and what care they needed. During an interview on 07/03/2025 at 1:15 P.M., the Assistant Director of Health Services (ADHS) stated she was not involved in the completion or submission of MDS assessments. She stated she expected all MDS assessments to be completed on time.During an interview on 07/03/2025 at 1:20 P.M., the Executive Director (ED) stated she was not involved in the MDS process, but she expected MDS assessments to be completed within the timeframes required. Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.19.1, dated 10/2024 indicated, The ARD [Assessment Reference Date] of an assessment drives the due date of the next assessment. The next non-comprehensive assessment is due within 92 days after the ARD of the most recent OBRA [Omnibus Budget Reconciliation Act] assessment (ARD of previous OBRA assessment - Admission, Annual, Quarterly, Significant Change in Status, or Significant Correction assessment - + 92 calendar days). The manual further specified, The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored.

Based on observation, interview, and record review, the facility failed to ensure a safe, clean, comfortable, and homelike environment by failing to ensure an intravenous (IV) pole utilized for tube feeding was clean for one (Resident #27) of two residents reviewed for tube feeding. The facility census was 50. Findings included:Review of Resident Face Sheet revealed the facility admitted Resident #27 on 01/17/2025 with diagnoses of cerebral palsy and dysphagia (difficulty swallowing). Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/25/2025, revealed Resident #27 had moderate impairment in cognitive skills for daily decision-making and had short-term and long-term memory problems per a Staff Assessment for Mental Status (SAMS). The MDS indicated that the resident required substantial to maximal assistance with eating and indicated the resident had a feeding tube. The MDS indicated the resident received greater than 51% of their total calories via feeding tube. Review of Resident #27's Care Plan included a problem statement, dated 06/30/2025, that indicated the resident required tube feeding related to dysphagia and cerebral palsy, which placed the resident at risk for complications. Interventions directed staff to administer eternal feedings per physician's orders (initiated 06/30/2025) and provide water flushes per physician's orders (initiated 06/30/2025). Review of Resident #27's Physician Order Report, for the timeframe from 01/01/2025 through 07/02/2025, included an active order for enteral feeding formula at a rate of 65 milliliters (ml) per hour for 12 hours a day, from 5:00 P.M. to 5:00 A.M., with an order date of 06/03/2025. During an observation on 06/30/2025 at 10:14 A.M. in Resident #27's room, an IV pole utilized to attach a pump for eternal feedings for Resident #27 had brown spots of a sticky liquid on the legs of the pole. During an observation on 07/03/2025 at 9:06 A.M. in Resident #27's room, the IV pole appeared dirty with the lower legs of the pole containing brown spots of a sticky substance. During an observation on 07/07/2025 at 4:12 A.M. in Resident #27's room, the IV pole's legs were dirty. During an interview on 07/07/2025 at 1:18 P.M., the Assistant Director of Health Services (ADHS) observed the IV pole in Resident #27's room and stated the legs appeared to have tube feeding contents which had dripped down the pole. She stated that it was dirty and should be cleaned. During an interview on 07/11/2025 at 9:10 A.M., the Executive Director stated she expected the equipment to be cleaned appropriately. She stated that the facility did not have a cleaning schedule or a policy regarding cleaning multi-use equipment. This deficiency represents non-compliance investigated under Complaint Number OH00163512.

Based on record review, interview, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure comprehensive Minimum Data Set (MDS) assessments were completed timely, which affected one (Resident #103) of 13 sampled residents. Specifically, the facility failed to ensure Resident #103's admission assessment was completed timely. The facility census was 50. Findings included:Review of Resident Face Sheet revealed the facility admitted Resident #103 on 06/23/2025 with a diagnosis of encephalopathy.Review of Resident #103's admission Minimum Data Set (MDS), with an admission Reference Date (ARD) of 06/30/2025, revealed the entry date (A1600), was entered as 06/23/2025. Per the MDS, the completion date (Z0500B), was dated 07/08/2025, 15 days after the entry date.During an interview on 07/08/2025 at 12:26 P.M., the MDS Coordinator stated that she had been trained that the admission MDS assessment was to be completed by the fourteenth day of the resident's stay, which would have been 07/06/2025 for Resident #103. She stated that the facility did not have a policy regarding MDS assessments and stated that she used the most recent version of the Resident Assessment Instrument (RAI) manual for completion date requirements.During an interview on 07/10/2025 at 3:00 P.M., the Assistant Director of Health Services (ADHS) stated she was unfamiliar with the MDS assessments completion date requirements. During an interview with the Executive Director on 07/11/2025 at 9:10 A.M., in regard to the timing of the completion of admission MDS assessments, the Executive Director stated staff should refer to the RAI manual to determine when admission MDSs should be completed. Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2024, revealed the section titled, 5.2 Timeliness Criteria, included, In accordance with the requirements at 42 CFR [Code of Federal Regulations] S483.20(f)(1), (f)(2), and (f)(3), long-term care facilities participating in the Medicare and Medicaid programs must meet the following conditions, which included Completion Timing. The manual revealed, For the admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600).

Based on observation, interview, and record review, the facility failed to ensure a tube feeding formula bag was labeled and dated for one (Resident #27) of two residents reviewed for tube feedings. The facility census was 50. Findings included:Review of Resident Face sheet revealed the facility originally admitted Resident #27 on 01/17/2025 and most recently admitted the resident on 05/28/2025. Resident #27 had a medical history that included diagnoses of cerebral palsy, pneumonitis due to inhalation of food or vomitus, gastrointestinal hemorrhage, encounter of attention to gastrostomy, gastrostomy malfunction, and dysphagia (difficulty swallowing). Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/25/2025, revealed Resident #27 had moderately impaired cognitive skills for daily decision-making and had short-term and long-term memory problems per a Staff Assessment for Mental Status (SAMS). The MDS indicated that the resident required substantial to maximal assistance with eating and indicated the resident had a feeding tube. The MDS indicated the resident received greater than 51% of their total calories via feeding tube. Review of Resident #27's Care Plan included a problem statement, dated 06/30/2025, that indicated the resident required tube feeding related to dysphagia and cerebral palsy, which placed the resident at risk for complications. Interventions directed staff to administer eternal feedings per physician's orders (initiated 06/30/2025) and to provide water flushes per physician's orders (initiated 06/30/2025). Review of Resident #27's Physician Order Report, for the timeframe from 01/01/2025 through 07/02/2025, included an active order for enteral feeding formula at a rate of 65 milliliters (ml) per hour for 12 hours a day, from 5:00 P.M. to 5:00 A.M., with an order date of 06/03/2025. An observation on 07/07/2025 at 4:12 A.M. revealed Resident #27 was in bed with tubing attached to an unlabeled bag of a tan-colored substance, which was running via a pump at 65 ml per hour. The tube feeding formula bag was not labeled with the resident's name, room number, date the feeding was hung, the time the bag was hung, the type/brand of the tube feeding formula, or the rate of infusion. During an observation on 07/07/2025 at 4:43 A.M., Licensed Practical Nurse (LPN) #1 entered the resident's room to flush Resident #27's feeding tube with water. After completing the water flush, LPN #1 removed the unlabeled bag of tube feeding formula and associated supplies and exited the resident's room. During a concurrent observation and interview on 07/07/2025 at 4:49 A.M., LPN #1 observed the tube feeding formula bag she removed from Resident #27's room and acknowledged it was not labeled. She stated she could not determine what type/brand of tube feeding had been provided to Resident #27 (because the bag was not labeled). She stated she knew that the tube feeding bag should be labeled to identify the ordered type/brand of tube feeding and when it was started. LPN #1 stated the tube feeding formula bag was hung by the nurse on day shift on 07/06/2025, and she had not noticed the bag was not labeled when she had been in to care for the resident during her shift. During an interview on 07/08/2025 at 7:45 A.M., LPN #2 stated she worked on day shift (7:00 A.M. to 7:00 P.M.) on 07/06/2025. She verified she hung and started Resident #27's tube feeding formula around 5:00 PM (on 07/06/2025). She said that because the pumps used in the facility and the original container of the ordered tube feeding formula were not compatible, she emptied the contents of the feeding formula into a disposable tube feeding bag before hanging it to be infused. She said she usually put the date and time the bag of feeding formula was hung on a sticker affixed to the bag. LPN #2 stated the stickers she used to label the tube feeding formula bags were known to fall off because they did not adhere well and could have fallen off. LPN #2 further stated she did not attempt to reinforce the sticker; she stated in the past, she had written the required information directly on the bag, but had not done that when she hung Resident #27's feeding formula on 07/06/2025. During an interview on 07/10/2025 at 2:44 P.M., the Assistant Director of Health Services (ADHS) stated feeding formula bags were to be labeled with the resident's name, room number, date and time the feeding was hung, the type/brand of the feeding formula, and the rate of infusion.

Based on observation, interview, record review, and facility standard operating procedure review, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) during close-contact activities for residents on enhanced barrier precautions (EBP), which affected one (Resident #27) of two residents reviewed for tube feeding and one (Resident #26) of two residents reviewed for non-pressure related skin conditions. The facility census was 50.Findings included: 1. Review of Resident Face Sheet revealed the facility admitted Resident #27 on 01/17/2025. The resident had a medical history that included diagnoses of cerebral palsy and dysphagia (difficulty swallowing). Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/25/2025, revealed Resident #27 had moderate impairment in cognitive skills for daily decision-making and had short-term and long-term memory problems per a Staff Assessment for Mental Status (SAMS). The MDS indicated that the resident required substantial to maximal assistance with eating. The MDS indicated the resident had a feeding tube and received greater than 51% of their total calories via feeding tube. Review of Resident #27's Care Plan, included a problem statement dated 06/30/2025, that indicated the resident required tube feeding related to dysphagia and cerebral palsy, which placed the resident at risk for complications. Interventions directed staff to administer eternal feedings per physician's orders (initiated 06/30/2025) and provide water flushes per physician's orders (initiated 06/30/2025). Review of Resident #27's Physician Order Report, for the timeframe from 01/01/2025 through 07/02/2025, included an active order dated 06/03/2025 for enteral feeding formula at a rate of 65 milliliters (ml) per hour for 12 hours a day, from 5:00 P.M. to 5:00 A.M. The Physician Order Report also included an order dated 05/28/2025 for staff to use EBP, wearing a gown and gloves at minimum during high contact activities. During an observation on 07/07/2025 at 4:43 A.M., License Practical Nurse (LPN) #1 entered Resident #27's resident's room, where there was signage posted on the door that indicated Resident #27 was on EBP. LPN #1 entered the room, carrying a pair of gloves and two partially filled glasses of water in hand. LPN #1 donned a pair of gloves and turned off Resident #27's tube feeding pump. LPN #1 placed a plunger barrel into Resident #27's feeding tube and allowed water to flow by gravity to flush the tube before capping off the tube. LPN #1 then removed the used syringe, the bag of unused water, and the bag of unused, tan-colored liquid from the feeding pump and took it from Resident #27's room. LPN #1 did not don a gown during the observation. During an interview on 07/07/2025 at 4:49 A.M., LPN #1 stated that she was aware Resident #27 was on EBP, and she had been taught to don a gown and gloves when completing care of the feeding tube. She stated she forgot to don a gown when she completed the care of Resident #27's feeding tube. During an interview on 07/07/2025 at 9:13 A.M., the Assistant Director of Health Services stated Resident #27 was on EBP and that she expected LPN #1 to don a gown and gloves when providing care of the feeding tube. During an interview on 07/11/2025 at 7:28 A.M., the Director of Health Services stated a resident on EBP had signage on their door indicating the resident was on EBP, and a PPE cart outside their room. She stated staff should wear standard EBP PPE, such as a gown, gloves, and goggles. 2. Review of Resident Face Sheet revealed the facility admitted Resident #26 on 06/07/2025. The resident had a medical history that included diagnoses of cellulitis of right and left lower extremities, open wound of the left and right lower extremities, methicillin resistant staphylococcus aureus (MRSA), and diabetic peripheral angiopathy without gangrene other bacterial infections of unspecified site. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/10/2025, revealed Resident #26 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. The MDS indicated the resident was at risk for developing pressure ulcers/injuries, and indicated the resident had moisture associated skin breakdown present. Review of Resident #26's Care Plan, included a problem statement dated 06/20/2025, that indicated the resident was at risk for skin breakdown related to cellulitis of the bilateral lower extremities. Interventions directed staff to provide treatments/preventative treatments as ordered (initiated 06/20/2025). Review of Resident #26's Physician Order Report, for the timeframe from 06/02/2025 through 07/02/2025, revealed an active order dated 06/30/2025 to cleanse open area to left lateral shin with normal saline, pat dry, apply a dressing, and cover with rolled gauze, then compression wrap daily for wound management. The Physician Order Report also revealed an order dated 06/12/2025 that indicated staff were to use EBP, wearing a gown and gloves at minimum during high-contact activities. During an observation on 07/03/2025 at 1:35 P.M., Registered Nurse (RN) #3 was wearing gloves and provided wound care to Resident #26's left leg. RN #3 did not don a gown before providing the wound care. During an interview on 07/03/2025 at 2:13 P.M., RN #3 stated she had been trained that when providing wound care for a resident on EBP, staff were to wear a gown and gloves, and she knew when residents were on EBP because a sign would be on the door. RN #3 looked at Resident #26's room door and acknowledged the resident was on EBP. She stated she forgot to don a gown before beginning wound care for the resident. During an interview on 07/10/2025 at 2:44 P.M., the Assistant Director of Health Services stated that RN #3 should have donned a gown and gloves before providing wound care to Resident #26. During an interview on 07/11/2025 at 7:28 A.M., the Director of Health Services stated residents on EBP had signage on their door indicating the resident was on EBP, and a PPE cart outside their room. She stated staff should wear standard EBP PPE, such as a gown, gloves, and goggles when they provided wound care. During an interview on 07/11/2025 at 9:10 A.M., the Executive Director stated she referred questions related to EBP to clinical staff. Review of the facility standard operating procedure titled, Enhanced Barrier Precautions (EBP) Standard Operating Procedure, revised 04/02/2024, revealed, Guidance for enhanced barrier precautions (EBP) to decrease risk of becoming colonized and developing infections with multidrug-resistant organism (MDRO) status. EBP does not replace existing guidance regarding the use of Contact precautions for other pathogens (ie [id est, that is]: Cdiff [clotridoides difficile colitis], scabies, norovirus etc [et cetera, and so forth]. The policy revealed, 1. Enhanced Barrier Precautions (EBP) will be in place during high-contact activities for residents with the following conditions, including Residents at an increased risk of MDRO acquisition which include: i. All residents with chronic wounds, including but not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. ii. All Residents with indwelling medical devices, which included feeding tubes. The policy revealed, 2) Personal Protective Equipment (PPE) should be used even if blood and body fluid exposure is not anticipated. a) At minimum, staff shall wear gloves and gowns during high-contact care activities. The policy revealed, 3. High-contact care activities include but are not limited to: morning ADL [activity of daily living] care, toileting, and showers.

Based on record review, interview, and facility policy review, the facility failed to notify a physician of the facility's failure to administer ordered medications in a timely manner to three (Residents #46, #107, and #199) of four residents reviewed for notification of changes. Additionally, the facility failed to notify the Infectious Disease specialist of the addition of an antifungal medication for Resident #107. The facility census was 50. Findings included:1. Review of Resident Face Sheet revealed the facility admitted Resident #199 on 02/08/2025 with diagnoses of cellulitis of the right and left lower limbs and methicillin-resistant Staphylococcus aureus (MRSA) infection. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/13/2025, revealed Resident #199 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. The MDS indicated Resident #199 did not reject care during the assessment's lookback period. The MDS revealed the resident had intravenous (IV) access on admission and while a resident. The MDS indicated Resident #199 admitted from a short-term general hospital. Revie of Resident #199's Care Plan History, included a problem statement dated 02/19/2025, that indicated the resident required enhanced barrier precautions (EBP) during high-contact care related to the presence of a wound with dressing changes. Interventions directed staff to observe for and report any new or worsened signs/symptoms of infection. Review of Resident #199's Out-patient antibiotic therapy ([NAME])/Antibiotic Infusion orders, dated 02/07/2025, indicated the resident was to receive IV meropenem (an antibiotic) 1 gram (g) every eight hours and linezolid (an antibiotic), 600 milligrams (mg) by mouth every 12 hours, to complete 02/21/2025. The [NAME]/Antibiotic Infusion orders, indicated Resident #199 had bilateral leg wounds with a polymicrobial infection including MRSA infection. Review of Resident #199's View Prescription Order, received 02/09/2025 and started 02/10/2025, revealed a written physician's order for meropenem 1 g IV every eight hours, first administration time 12:00 A.M. Review of Resident #199's Physician Order Report, dated from 02/01/2025 through 07/02/2025, included an order for meropenem 1 g IV every eight hours at 12:00 A.M., 8:00 A.M., and 4:00 P.M., started on 02/10/2025. The Physician Order Report included an order for linezolid 600 mg by mouth every 12 hours for 14 days, started on 02/09/2025. Review of Resident #199's 02/2025 Medication Administration History revealed meropenem was not administered as scheduled on 02/10/2025 at 12:00 AM or 8:00 A.M. The Medication Administration History revealed staff documented that they administered the meropenem late on 02/10/2025 at 12:57 P.M. Further review revealed linezolid was not administered as scheduled on 02/09/2025 and 02/10/2025 from 7:00 A.M. to 11:00 A.M. The Medication Administration History revealed staff documented that they administered linezolid late on 02/10/2025 at 12:57 P.M. During an interview on 07/08/2025 at 2:06 P.M., the Medical Director (MD) stated he was unaware that Resident #199's IV antibiotics were not started on admission but two days after admission. The MD stated he expected medications to be available to be administered as ordered and to be notified if medications could not be administered so the orders could be potentially modified or to provide further instructions, because when antibiotics were missed it resulted in a delay in treatment. On 07/11/2025 at 7:28 A.M., interview with the Director of Health Services (DHS) revealed they would call the doctor to see what they could do if they were not able to get the resident's medications right away. The DHS stated they should have gotten an order from the doctor as to when they wanted them to start medications for Resident #199. 2. Review of the Resident Face Sheet revealed the facility admitted Resident #107 on 03/20/2025 at 6:55 PM. with diagnoses of cellulitis of the right upper and lower limb, gangrene, Group B Streptococcus (a bacteria), aftercare following a surgical amputation, and acquired absence of the right finger. Review of the admission Minimum Data Set (MDS), with an admission Reference Date (ARD) of 03/24/2025, revealed Resident #107 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS also indicated that the resident did not reject care during the assessment's lookback period. The MDS revealed the resident received intravenous (IV) medications while a resident. The MDS indicated Resident #107 admitted from a short-term general hospital. Review of Resident #107's Care Plan History, included a problem statement dated 03/24/2025, that indicated the resident required enhanced barrier precautions (EBP) during high-contact care related to the presence of a wound with dressing changes and a central line. Interventions directed staff to observe for and report any new or worsened signs/symptoms of infection. Review of a physician's ID [Infectious Disease] progress note, dated 03/20/2025 and electronically signed on 03/20/2025 at 9:26 AM, indicated Resident #107 had a right index finger infection, bacteremia, and a diabetic foot infection. The ID progress note indicated the illness posed a threat to life or bodily function. The ID progress note indicated recommendations included: continue daptomycin (an IV antibiotic) 6 mg/kg (milligrams/kilogram) IV every 24 hours; continue meropenem (an IV antibiotic) 1 g (gram) IV every 12 hours in house and at discharge transition to ertapenem 1 g IV every 24 hours; and continue daptomycin and ertapenem four weeks from the last surgical debridement. Review of Resident #107's Physician Discharge Summary, dated 03/20/2025 at 10:52 AM, indicated a discharge diagnosis of gangrene of the right hand. The Physician Discharge Summary indicated, Start taking these medications, and included daptomycin 400 mg IV daily; ertapenem 1 g every 24 hours; and 5,000 units of heparin subcutaneously every 12 hours. Review of Resident #107's hospital Discharge Summary, dated 03/20/2025 at 4:20 P.M., included discharge instructions dated 03/19/2025 at 2:58 PM that revealed a discharge medication list that included doxycycline 100 mg twice daily; ertapenem 1 g every 24 hours; and heparin 5000 units/ml subcutaneously every 12 hours. The Discharge Summary did not include instructions to start daptomycin. Review of Resident #107's Progress Notes included an IDT [Interdisciplinary Team] Infection note, dated 03/20/205 at 10:56 P.M., written by the Director of Health Services (DHS), that indicated Resident #107 admitted to the facility with an amputated right finger related to gangrene and bacteremia. The note indicated Resident #107 was on IV ertapenem and received doxycycline by mouth. The note revealed the resident was being followed by an infectious disease provider. Review of Resident #107's Physician Order Report, for the timeframe from 03/20/2025 through 04/04/2025, included orders for:- Doxycycline monohydrate (an antibiotic),100 mg capsule twice a day for cellulitis, started and ended on 03/21/2025.- Doxycycline monohydrate 100 mg capsule twice a day for cellulitis, started on 03/22/2025.- Ertapenem (an injectable antibiotic) 1 g IV for cellulitis, started and ended on 03/21/2025.- Ertapenem 1 g IV once a day for cellulitis, started on 03/22/2025.- Heparin, 5,000 unit/ml (milliliter) injected twice a day for deep vein thrombosis (DVT) prevention, started and ended on 03/21/2025.- Heparin, 5,000 unit/ml injected twice a day for deep vein thrombosis (DVT) prevention, started on 03/22/2025.- Micafungin (an antifungal medication), 100 mg IV once a day, started on 03/27/2025.The Physician Order Report did not include an order for daptomycin. Review of Resident #107's 03/2025 Medication Administration History revealed staff documented that Resident #107 received initial doses of heparin, doxycycline monohydrate, and IV ertapenem on 03/22/2025. The Medication Administration History revealed staff documented that heparin and doxycycline monohydrate were not available on 03/21/2025. The Medication Administration History did not include the transcription of an order for daptomycin. During an interview on 07/07/2025 at 1:26 P.M., the Assistant Director of Health Services (ADHS) reviewed Resident #107's discharge summary and verified the resident should have started daptomycin IV. The ADHS reviewed Resident #107's orders and stated it appeared the order was omitted. During a follow-up interview on 07/08/2025 at 9:55 A.M., the ADHS stated she had reviewed Resident #107's medical chart and the staff entered orders from an after-visit summary (AVS) record when Resident #107 was admitted , which did not include daptomycin. The ADHS stated the AVS was completed after the discharge summary and infection disease note, so there was no need to contact a provider to question it. During an interview on 07/08/2025 at 10:36 A.M., the Infectious Disease (ID) Nurse Practice Manager reviewed Resident #107's medical record and stated the ID provider cared for the resident during their hospital admission from 03/11/2025 to 03/20/2025. The ID Nurse Practice Manager stated the ID provider wrote orders for Resident #107 to discharge to the skilled nursing facility (SNF) on daptomycin and ertapenem daily until 04/15/2025. The ID Nurse Practice Manager stated she did not see where the ID provider changed Resident #107's order from daptomycin to doxycycline. The ID Nurse Practice Manager stated Resident #107 was seen in the office for a follow-up visit on 04/03/2025, and the provider was unaware the resident was not receiving both daptomycin and ertapenem and was unaware of the addition of micafungin. During an interview on 07/08/2025 at 2:06 P.M., the Medical Director (MD) stated he expected medications to be available to be administered as ordered. The MD stated he expected to be notified if medications could not be administered so the orders could be potentially modified or to provide further instructions, because when antibiotics were missed it resulted in a delay in treatment. During an interview on 07/10/2025 at 3:00 P.M., the ADHS stated nurses should contact the doctor to confirm orders were correct. On 07/11/2025 at 7:28 AM, interview with the Director of Health Services (DHS) revealed the doctor was called if the facility could not get resident medications right away. The DHS stated Resident #107 was admitted with orders for heparin, doxycycline, and ertapenem that should have been administered and the doctor notified if they were not available. 3. Review of the Resident Face Sheet revealed the facility admitted Resident #46 on 04/12/2025 at 5:19 P.M. with diagnoses of of aftercare following surgery for neoplasm, acute respiratory failure with hypoxia, pneumonia due to Pseudomonas (a bacteria), pulmonary fibrosis, interstitial lung disease, systemic stenosis with lung involvement, malignant neoplasm of upper lobe, left bronchus, or lung, and pulmonary hypertension. Review of the 5-day Minimum Data Set (MDS) with an admission Reference Date (ARD) of 04/17/2025 revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS also indicated Resident #107 did not reject care during the assessment's lookback period. The MDS revealed the resident received intravenous (IV) medications while a resident. The MDS indicated Resident #107 admitted from a short-term general hospital. Review of Resident #46's Care Plan History, included a problem statement dated 04/14/2025, that indicated the resident required IV medications related to pneumonia. Interventions directed staff to administer IV medications as ordered. Review of Resident #46's hospital Inpatient Discharge Summary, dated 04/12/2025, indicated the resident's discharge medications included a new prescription for cefepime (an antibiotic), 2 grams (g) IV every eight hours for four days. Review of Resident #46's Physician Order Report, dated from 04/01/2025 through 07/01/2025, included an order for cefepime, 2 g IV every eight hours for four days, started on 04/12/2025 and ended on 04/15/2025. Review of Resident #46's 04/2025 Medication Administration History, revealed staff documented that they administered cefepime 2 g on 04/13/2025 at 4:00 PM, and the medication was discontinued after the resident received six doses. The Medication Administration History revealed staff documented that cefepime was awaiting on 04/12/2025 at 10:17 P.M.; none on 04/13/2025 at 3:04 A.M., and drug/item unavailable on 04/13/2025 at 12:04 P.M. During an interview on 07/01/2025 at 3:04 P.M., Registered Nurse (RN) #9 stated she did not contact the pharmacy to find out when the medication would arrive or contact the medical provider that the medication was unavailable to administer on 04/13/2025 at 4:00 A.M. because she thought the medication would arrive later that day. During an interview on 07/01/2025 at 3:36 P.M., Licensed Practical Nurse (LPN) #5 stated she did not recall contacting the provider about the antibiotic's unavailability because she thought it would start later that day. During an interview on 07/01/2025 at 3:58 P.M., LPN #10 revealed she was on duty on 04/12/2025 when Resident #46's 8:00 P.M. dose of IV cefepime was due; however, it had not arrived from the pharmacy. LPN #10 revealed she did not contact the pharmacy or the medical provider to notify them that the medication was unavailable to be administered because she thought the medication would arrive the next day for administration. During an interview on 07/02/2025 at 9:25 A.M., the Director of Assisted Living (DAL) stated anytime a medication was not available nurses were to call the pharmacy and notify the physician of the unavailability of the medication unless the medication arrived before the end of the medication administration pass. On 07/11/2025 at 7:28 A.M., interview with the Director of Health Services (DHS) revealed the doctor was called if the facility could not get resident medications right away. Review of the facility policy titled, Physician-Provider Notification Guidelines, last reviewed by the facility on 12/17/2024, revealed, The purpose of this policy is to: To [sic] ensure the resident's physician or practitioner (may include NP [nurse practitioner], PA [physician assistant], or clinical nurse specialist) is aware of all diagnostic testing results or change in condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care.

Based on medical record review, staff interviews and policy review, the facility failed to ensure documentation was completed regarding a resident's meal/dietary intake. This affected one (#45) out of three residents reviewed for meal service. The facility census was 43. Findings include: Medical record review for Resident #45 revealed an admission on 04/16/24 and a discharge on 04/18/24. Diagnoses include acute kidney failure, asthma, and cerebral infarction without deficits. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #45 was not completed due to discharge from the facility. Review of the baseline plan of care dated 04/16/24 for Resident #45 revealed the resident was on a regular diet, mechanical soft with thin liquids. Review of the active physicians' orders for Resident #45 revealed an order dated 04/16/24 stating regular diet, mechanical soft with thin liquids. Review of the electronic health record for Resident #45 for dietary intake revealed there was no documentation the resident consumed any meals during her stay at the facility. Interview on 05/28/24 at 2:10 P.M. with the Director of Nursing (DON) verified the facility did not have any documentation for Resident #45's meal intake during the resident's stay. DON stated the staff should be documenting the percentage of food consumed at each meal in the electronic health record. Review of the facility policy titled Meal Service, dated 01/2024 revealed if an individual is not accepting of their food an appropriate an alternate is offered and the staff will assist the individual as needed. This deficiency represents non-compliance investigated under Complaint Number OH00153301.

Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure staff utilized proper hand hygiene during wound dressing change procedures. This affected one (#06) resident of three residents reviewed for wound care. The facility census was 47. Findings include: Review of the medical record for Resident #06 revealed an admission on 02/01/24 with diagnoses including, but not limited to, fracture of lower end of left radius, encephalopathy, rhabdomyolysis, atherosclerotic heart disease, peripheral vascular disease, chronic obstructive pulmonary disease, and stroke. Review of the admission Minimum Data Set (MDS) assessment for Resident #06 dated 02/06/24 revealed the assessment was still in progress. Review of the plan of care dated 02/13/24 for Resident #06 revealed the resident had a pressure ulcer. Interventions include medications as ordered, assess, and record the condition of skin, observe and report signs of infection, observe for and report signs of pain related to pressure, pressure cushion to chair and mattress, diet as ordered, and weekly skin assessments. Review of the physician orders dated 02/13/24 for Resident #06 revealed the resident was ordered to have the pressure ulcer on the left hip cleansed with normal saline and apply nickel thick layer of Santyl ointment 250 units/gram, cover with alginate pad and secure with a foam dressing every other day and as needed (PRN) for soiling or dislodgement. Observations of wound care for Resident #06 on 02/15/24 at 10:00 A.M. with Licensed Practical Nurse (LPN) #86 revealed the residents bed side table was wiped down with sani-wipes and draped with a towel. The wound supplies were placed on the towel and pulled close to the resident's bedside. LPN #86 completed hand hygiene with soap and water, then donned gloves. The dressing to resident's left hip was removed and placed into the plastic trash bag. LPN #86 proceeded to cleanse the wound with normal saline and four by four gauze pads. LPN #86 then removed her gloves, completed hand hygiene, donned gloves, and applied Santyl ointment to the wound bed. LPN #86 applied collagen alginate to wound bed and covered with foam bordered dressing. Interview with LPN #86 n 02/15/24 at 10:15 A.M. revealed she was unsure of what the policy stated regarding hand hygiene and confirmed she removed old dressing from left hip and cleanse the wound without changing her gloves. Interview with the Director of Nursing (DON)on 02/15/24 at 11:00 A.M. revealed LPN #86 should have removed her gloves after removing the old wound dressing and completed hand hygiene prior to the application of the new dressing. Review of the facility policy titled Dressing Changes, dated 12/31/23 revealed to ensure measures that will promote and maintain good skin integrity while maintaining standard measures that will minimize and control contamination. The staff would remove soiled dressing and discard it in plastic bag or trash can, remove and dispose of gloves and wash hands with soap and water. Then apply a second pair of disposable gloves and follow physician orders for application of treatments.

Based on medical record review, observations, staff and resident interviews and policy review, the facility failed to maintain an effective pest control program. This had affected two (#10 and #36) out of two residents reviewed for pest control. The facility census was 52. Findings include: 1. Record review for Resident #10 revealed she was admitted to the facility on [DATE]. Diagnoses include acute and chronic [CONDITION(S)] with [CONDITION(S)], heart failure, chronic [CONDITION(S)] with [CONDITION(S)], [CONDITION(S)] disease, [CONDITION(S)] heart, old [CONDITION(S)], chronic obstructive pulmonary disease, asthma, polyneuropathy, diabetes mellitus two, [CONDITION(S)] of intestine, major depressive disorder, obesity, sleep apnea, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #10 had intact cognition. Further review of the MDS assessment revealed she required extensive assistance from staff with bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #10 required limited assistance from staff with eating. 2. Record review for Resident #36 revealed an admitted [DATE]. Diagnoses included arthropathy, hypertensive urgency, asthma, [CONDITION(S)], diabetes mellitus two, depression, [CONDITION(S)], [CONDITION(S)], dysphagia, hypertension, gastro-[CONDITION(S)] reflux disease without esophagitis, and [CONDITION(S)]. Review of the quarterly MDS assessment, dated 07/13/22, revealed Resident #36 had impaired cognition. Further review of the MDS assessment revealed she required supervision from staff with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Observation on 08/16/22 at 9:51 A.M. during an interview with Resident #36 revealed the resident was sitting on the side of the bed. Observation of the wall next to her bed revealed a large colony of ants crawling all over the wall, over the bedside chair, and along the carpet. Interview on 08/16/22 at 10:07 A.M. with Licensed Practical Nurse (LPN) #53 confirmed ants were crawling all over the chair, up the wall and all over the floor in Resident #36's room. Interview on 08/16/22 at 12:38 P.M. with Resident #10 stated she has had an ongoing issue with ants in her room. Interview on 08/17/22 at 8:48 A.M. with Maintenance Supervisor (MS) #68 revealed the facility utilizes a professional pest control company to spray for pest monthly. MS #68 stated the facility is treated monthly, however, if pest are identified in a resident's room the facility maintenance staff will treat until the next monthly visit from the professional pest control program. MS #68 confirmed Resident #36 had an infestation of ants in her room and the issue should have been referred to the professional pest control company for treatment. Follow up interview on 08/17/22 at 3:42 P.M. with the MS #68 confirmed the facility has never had Resident #10 or Resident #36's room treated by the professional pest control company utilized by the facility. MS #68 confirmed each room had ant infestation. Review of the facility policy tiled Pest Control dated 08/07/2018, revealed the facility will maintain an ongoing pest control program to ensure the building is kept free of insects and rodents.

Based on medical record review and staff interview, the facility failed to provide written notification to the resident and/or their representative prior to the resident's transfer to the hospital. This affected four (#10, #36, #50 and #204) out of four residents reviewed for discharge from the facility. The facility census was 52. Findings include: 1. Record review for Resident #10 revealed she was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #10 had intact cognition. Further review of the MDS assessment revealed she required extensive assistance from staff with bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #10 required limited assistance from staff with eating. Review of Resident #10's nursing progress notes revealed she was discharged to the hospital on 05/08/22 and returned to the facility on [DATE]. Resident #10 discharged to the hospital on 08/08/22 and returned to the facility on [DATE]. Further review of Resident #10's medical record revealed there was no evidence of the facility providing the resident and/or their representative with a written notification regarding the resident's transfer to the hospital. 2. Record review for Resident #36 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment, dated 07/13/22, revealed Resident #36 had impaired cognition. Further review of the MDS assessment revealed she required supervision from staff with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Review of Resident #36's progress notes revealed she was discharged from the facility on 06/24/22 and admitted to the hospital. Resident admitted to the facility from the hospital on 06/29/22. Further review of Resident #36's medical record revealed there was no evidence of the facility providing the resident and/or their representative with a written notification regarding the resident's transfer to the hospital. 3. Record review for Resident #50 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment, dated 07/15/22, revealed Resident #50 had impaired cognition. Further review of the MDS assessment revealed he required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. He required supervision from staff with eating. Review of the nursing progress notes for Resident #50 revealed he was discharged to the hospital on 06/22/22. Resident #50 readmitted to the facility on [DATE] as a new admission. Further review of Resident #50's medical record revealed there was no evidence of the facility providing the resident and/or their representative with a written notification regarding the resident's transfer to the hospital. 4. Record review for Resident #204 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the five day MDS assessment, dated 08/08/22, revealed he had impaired cognition. Further review of the MDS assessment revealed he required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. He required supervision from staff with eating. Review of the nursing progress notes for Resident #204 revealed he was discharged from the facility to the hospital on 07/19/22. Resident #204 returned from the hospital on 08/05/22. Further review of Resident #204's medical record revealed there was no evidence of the facility providing the resident and/or their representative with a written notification regarding the resident's transfer to the hospital. Interview on 08/17/22 at 3:06 P.M. with the Administrator confirmed the facility has failed to notify Resident #10, #36, #50, and #204 and/or their representative in writing of discharge from the facility.

Based on medical record review staff interview and review of the facility policy, the facility failed to provide notification of bed hold days available to residents who have discharged from the facility. This affected four (#10, #36, #50 and #204) out of four residents reviewed for discharge from the facility. The facility census was 52. Findings include: 1. Record review for Resident #10 revealed she was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #10 had intact cognition. Further review of the MDS assessment revealed she required extensive assistance from staff with bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #10 required limited assistance from staff with eating. Review of Resident #10's nursing progress notes revealed she was discharged to the hospital on 05/08/22 and returned to the facility on [DATE]. Resident #10 discharged to the hospital on 08/08/22 and returned to the facility on [DATE]. Further review of Resident #10's medical record revealed there was no evidence of the facility provided the resident and/or their representative with bed hold information when the resident was transfer to the hospital. 2. Record review for Resident #36 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment, dated 07/13/22, revealed Resident #36 had impaired cognition. Further review of the MDS assessment revealed she required supervision from staff with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Review of Resident #36's progress notes revealed she was discharged from the facility on 06/24/22 and admitted to the hospital. Resident admitted to the facility from the hospital on 06/29/22. Further review of Resident #36's medical record revealed there was no evidence of the facility provided the resident and/or their representative with bed hold information when the resident was transfer to the hospital. 3. Record review for Resident #50 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment, dated 07/15/22, revealed Resident #50 had impaired cognition. Further review of the MDS assessment revealed he required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. He required supervision from staff with eating. Review of the nursing progress notes for Resident #50 revealed he was discharged to the hospital on 06/22/22. Resident #50 readmitted to the facility on [DATE] as a new admission. Further review of Resident #50's medical record revealed there was no evidence of the facility provided the resident and/or their representative with bed hold information when the resident was transfer to the hospital. 4. Record review for Resident #204 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the five day MDS assessment, dated 08/08/22, revealed he had impaired cognition. Further review of the MDS assessment revealed he required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. He required supervision from staff with eating. Review of the nursing progress notes for Resident #204 revealed he was discharged from the facility to the hospital on 07/19/22. Resident #204 returned from the hospital on 08/05/22. Further review of Resident #204's medical record revealed there was no evidence of the facility provided the resident and/or their representative with bed hold information when the resident was transfer to the hospital. Interview on 08/17/22 at 3:06 P.M. with the Administrator confirmed the facility has failed to notify Resident #10, #36, #50, and #204 of their bed hold days. Review of the facility policy titled, Bed Hold Notification, dated 11/18/16, revealed incases of emergency transfers, the notice of bed hold policy under the state plan and facility's bed hold policy should be provided to the resident or resident's representative by nursing designees within 24 hours of transfer. This may be sent with other papers accompanying the resident to the hospital.

Based on medical record review, observation, and staff interview, the facility failed to offer and/or provide assistance with eating for a resident who required extensive assistance with eating. This affected one (#29) of three residents reviewed for needing assistance with eating. The census was 52. Findings include: Medical record review for Resident #29 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] reveled the resident was severely cognitively impaired. Resident #29 required extensive assistance with transfers, bed mobility, dressing, toileting, maintaining hygiene, and eating. Review of Resident #29's care plan dated 06/20/22 revealed the resident experienced significant weight loss due to poor intake and end of life care. Interventions included, provide diet, supplements, medications, adaptive equipment, and snacks as ordered, obtain weights as ordered, and offer encouragement and assistance with eating as needed. Further review of the care plan revealed the resident had impairment in functional status regarding eating and required set up to extensive assistance with eating. Observation on 06/22/22 at 8:58 A.M. revealed Resident #29 was sitting in the common area with her breakfast tray in front of her. Resident #29 had coffee, orange juice, milk, pureed oatmeal, and yogurt on her tray. The resident's silverware was still wrapped in a cloth napkin and her food was uneaten. Observation on 06/22/22 at 9:36 A.M. revealed State tested Nurse Aide (STNA) #56 collecting breakfast trays. Resident #29 still had not eaten her food and the silverware was still wrapped in the cloth napkin. STNA #56 picked up the resident's untouched tray without offering to assist the resident with eating. Interview on 06/22/22 at 9:36 A.M. STNA #56 reported Resident #29 had poor appetite due to a decline in condition. When asked if Resident #29 was assisted with breakfast, STNA #56 stated she thought another STNA assisted the resident. STNA #56 was observed speaking with another STNA and then verified the resident was not assisted with eating breakfast and verified the resident had not eaten breakfast and her tray was removed without offering assistance. Observation on 06/23/22 at 9:11 A.M. revealed Resident #29 was asleep in bed with her breakfast tray located on a bedside table, behind the food of the bed and out of reach from the resident. Resident #29 had a bowl of oatmeal, milk, and orange juice. Food and beverages appeared to be uneaten, and the resident's silverware was still wrapped in a cloth napkin. Observation on 06/23/22 at 9:35 A.M. revealed Resident #29 continued to be asleep with her breakfast tray still out of reach and food uneaten. STNA #62 entered Resident #29's room to collect her roommate's tray and did not provide encouragement to Resident #29 to eat. Interview on 06/23/22 at 9:35 A.M. STNA #62 verified no staff had assisted Resident #29 with eating and her breakfast tray was out of reach and uneaten. Observation on 06/23/22 at 9:50 A.M. STNA #4 entered Resident #29's room to assist her with eating. Resident #29 was observed eating her oatmeal with assistance. This deficiency substantiates Complaint Number OH 421.

Based on medical record review, observation, staff interview, and review of the Standard Operating Procedure for Dressing Changes, the facility failed to ensure proper infection control procedures were following when providing wound care. This affected one (#35) of three residents reviewed for infection control. The facility census was 52. Findings include: Review of the medical record for Resident #35 revealed an admitted [DATE]. Pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #35 was cognitively intact. The resident required extensive assistance with bed mobility, dressing, and maintaining hygiene and was totally dependent on staff for transfers and toileting. Resident #35 was at risk for pressure ulcers. Observation on 06/22/22 at 11:45 A.M. revealed Registered Nurse (RN) #88 and State tested Nurse Aide (STNA) #56 providing wound care to Resident #35. RN #88 was observed washing her hands prior to the treatment and applied gloves. RN #88 was observed removing the packing to the resident's abdominal wound. The area was cleansed with normal saline. RN #88 removed her gloves and applied new gloves without washing her hands or using hand sanitizer. RN #88 packed the abdominal wound with Dakin's soaked Kerlix, covered it with an abdominal pad, and secured it with paper tape. RN #88 did not wash her hands or use hand sanitizer and applied a clean pair of gloves. RN #88 proceeded to remove the dressing to his left leg dressing removed, noted to have yellow drainage. The area was cleansed, RN #88 removed her gloves and applied new gloves without washing her hands or using hand sanitizer. She proceeded to apply calcium alginate to the wound and cover it with abdominal pads, wrap the area with kerlix, secure with cloth tape, and applied an ace wrap. Continued observation at 12:00 P.M. revealed RN #88 moved on to providing wound care to the resident's open area on his bilateral buttocks. The wound was not covered by a dressing. STNA #56 indicated she removed it approximately 20 minutes prior in preparation for the treatment, leaving the wound in contact with the bed sheet. The area was cleaned and Santyl was applied to the yellow areas. The wound was covered with calcium alginate, abdominal pads, and a brief was placed under the resident's buttocks to secure the dressing. The resident could not tolerate the brief, so it was removed, and pads were placed between the resident and the bedding. Interview on 06/22/22 at 1:07 P.M. the Director of Nursing (DON) verified RN #88 should have washed her hands between changing gloves when providing wound care. Review of the Standard Operating Procedure for Dressing Changes dated 05/11/16 revealed under section, Under the Standard Operating Procedure Details, the nurse was to 1) Place plastic bag or trash can near to dispose the soiled dressing 2) Create a clean field 3) Remove old adhesive with adhesive remover, if necessary, taking care not to get solution into the wound 4) wash hands with soap and water 5) Open dressing pack 6) Put on first pair of disposable gloves 7) Remove soiled dressing and discard in plastic bag or trash can 8) Dispose of gloves in plastic bag or trash can 9) wash hands with soap and water 10) Put on second pair of disposable gloves 11) Follow doctor's recommendations for treatment 12) Apply dressing and secure with tape when done with treatment if necessary 13) If using scissors make sure, it is clean with antiseptic after contact with soiled dressings 14) Remove gloves and discard 15) wash hands with soap and water 16) assist resident to comfortable position with call light in reach and 17) discard soiled dressings per protocol.

Based on record review, staff interview, and review of the facility's policy, the facility failed to notify a resident's representative of a newly acquired pressure ulcer. This affected one (Resident #23) of three residents reviewed for pressure ulcer care and treatment. The facility census was 36. Findings include: Review of the medical record for Resident #23 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment, for Resident #23 dated 06/03/21, revealed the resident was cognitively impaired. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's medical record, from 04/16/21 to 04/18/21, revealed there was no evident the resident's representative was notified of the new physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 07/01/21 at 1:20 P.M. with Registered Nurse (RN) #66 confirmed State tested Nursing Assistant (STNA) notified her on 04/16/21 of a new open area to Resident #23's coccyx. RN #66 confirmed she did not notify the resident's representative of the new pressure ulcer to the resident's coccyx and new physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 07/01/21 at 3:52 P.M. with the Administrator confirmed Resident #23's medical record was silent regarding notification of resident representative of a new pressure ulcer to her coccyx first identified on 04/16/21. Review of the facility's undated policy titled 'Guidelines for Change in Resident Condition' revealed upon assessment of the resident's change in status, the licensed professional nurse will assess the resident for a change in condition and will document in the resident's medical record. In addition, the nurse will notify the responsible party and will document the same in the electronic health record (EHR) reflecting date and time of notification. This was an incidental finding during the course of the complaint investigation.

Based on record review, observation, staff interview, and review of the facility's policy, the facility failed to assess and monitor a resident's pressure ulcer. This affected one (Resident #23) of three residents reviewed for pressure ulcer care and treatment. The facility identified three residents with pressure ulcers. The facility census was 36. Findings include: Review of the medical record for Resident #23 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment for Resident #23, dated 06/03/21, revealed the resident was cognitively impaired, required extensive assistance of one to two staff with activities of daily living (ADLs). Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was also an order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurse practitioner (NP) provider note for Resident #23, dated 04/26/21, revealed the resident was seen for management of chronic disease and gradual decline and exhibited no recent distress and note was silent regarding the presence of skin breakdown. Review of the physician orders, dated 05/10/21, revealed an order to cleanse the wound to the coccyx with normal saline, apply skin prep to the surrounding skin, apply [MEDICATION(S)] to the wound bed, and cover with foam dressing every three days and as needed. Review of the medical record for Resident #23 revealed it was silent regarding a description of the wound or measurements of the wound to the resident's coccyx from 04/16/21 through 06/03/21. Hospice was monitoring the wound but not routinely. Review of the facility's wound measurements and assessment for Resident #23 revealed the first assessment was completed on 06/04/21 and revealed the resident had an unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar) to her coccyx measuring 1.3 centimeters (cm.) in length by 1.0 cm. in width. Depth of the wound could not be measured due to slough covering the wound bed. Review of the care plan for Resident #23 revealed a care plan for the resident's pressure ulcer was not created until 06/04/21. The care plan, dated 06/04/21, revealed the resident had a pressure ulcer to coccyx and was at risk for further decline and complications related to immobility, malnutrition, need for assistance with turning/repositioning and ADLs, and incontinence. Interventions included to use a moisture barrier product to the perineal area, provide incontinence care after each incontinent episode, use cushion for pressure reduction when resident was in chair, avoid friction and shearing forces during transfer and position changes, turn and reposition routinely and as needed as the resident will allow, supplements as ordered, diet as ordered, assess and record the condition of the skin surrounding the pressure ulcer, assess the pressure ulcer for location, stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization during weekly rounds, conduct a systematic skin inspection weekly and additionally as needed, report any signs of further skin breakdown, keep linens clean, dry, and wrinkle free, keep clean and dry as possible, minimize skin exposure to moisture, maintain the head of the bed at the lowest degree of elevation, and keep bony prominences from direct contact with one another, as tolerated. Review of the facility's wound measurements and assessment for Resident #23 dated 06/30/21 revealed the resident had a stage four pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed.) to her coccyx measuring 1.5 cm. in length by 1.0 cm. in width and 3.0 cm. in depth. The wound had a light amount of serous exudate. Observation on 07/01/21 at 8:05 A.M. of wound care for Resident #23 per Registered Nurse (RN) #80 assisted by the Director of Nursing (DON), and Licensed Practical Nurse (LPN) #68 revealed the resident had a wound to her coccyx which appeared to be approximately 2.0 cm. in length by 2.0 cm. in width by 1.5 cm. in depth. Interview on 07/01/21 at 8:10 A.M. with RN #80 confirmed the facility identified the wound on Resident #23's coccyx as a stage four pressure ulcer. The RN confirmed the facility did not begin to regularly assess and measure the ulcer until 06/04/21. Interview on 07/01/21 at 1:20 P.M. with Registered Nurse (RN) #66 confirmed an State tested Nursing Assistant (STNA) notified her on 04/16/21 of a new open area to Resident #23's coccyx. RN #66 confirmed she obtained a treatment order but did not measure or document specifics of the area. Review of the facility's undated policy titled 'Pressure Ulcer Guidelines' revealed the facility would document a description of wounds weekly to include length, width, depth, exudate, color, odor, wound margins, surrounding tissue, tunneling and/or undermining if applicable. This deficiency substantiates Complaint Number OH 696.

Based on observation, staff interview, facility policy review and review of Centers for Medicare and Medicaid (CMS) and Centers for Disease Control (CDC) guidelines, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) in the facility to prevent the spread of COVID-19. This had the potential to affect 12 residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 and #12) of 30 residents residing in the facility. Findings include: During an observation of the COVID-19 quarantine (yellow zone) unit with the Administrator on 12/16/20 at 9:33 A.M. revealed State tested Nurses Aides (STNAs) #40 and #41 were observed to have exited Resident #1's room wearing KN95 respirators with ear loops that secured behind their ears. The observation also revealed Licensed Practical Nurse (LPN) #30 was in Resident #2's room with a KN95 respirator with ear loops that secured behind her ears. Interviews with LPN #30 and STNA's #40 and #4) indicated they received KN95 respirators at front desk when they were screened in. Interview at this time with the Administrator verified the staff were wearing KN95 respirators with ear loops on the COVID-19 quarantine unit. During an observation of the COVID-19 (red zone) unit on 12/16/20 at 9:40 A.M. revealed the Director of Nursing (DON) was observed to have a KN95 respirator in place with ear loops that were attached to paper clips and a plastic band across the top of her head. Further observation revealed STNAs #42, #43 and #44 were observed to be wearing KN95 respirators with ear loops that secured behind their ears. Interview with Administrator at this time verified the staff were wearing KN95 respirators with ear loops inside the COVID-19 unit. Observation of the facility's personal protective equipment (PPE) stock with the Administrator on 12/16/20 at 9:45 A.M. revealed numerous boxes of CDC / National Institute Occupational Safety and Health (NIOSH) approved N95 masks. Observation of the stock KN95 respirators that the DON and STNAs #40, #41, #42, #43 and #44 wore were labeled for non-medical use. Interview at same time with Administrator indicated the facility was not in a crisis strategy related to PPE equipment. The Administrator stated he was not aware the KN95 respirators that staff were wearing was not approved to be worn on the COVID-19 positive or the COVID-19 quarantine units. Subsequent observation of the COVID quarantine unit on 12/16/20 at 11:10 A.M. revealed Activities Assistant #10 was observed to be in Resident #6's room wearing a KN95 respirator with ear loops and a surgical mask underneath. Activities Assistant #10 had the surgical mask secured behind her ears and the ear loops of the KN95 respirator attached to paper clips and a home-made crocheted across the top of her head. Interview with Activities Assistant #10 at 11:20 A.M. verified she had on a surgical mask underneath a KN95 respirator with ear loops that secured behind her ears. Activities Assistant #10 stated she was not aware the KN95 respirator being worn was not an appropriate respirator to be worn on a COVID-19 quarantine unit and indicated she was not aware she could not wear a surgical mask underneath a respirator. Observation of diabetic care for infection control with LPN #30 on 12/16/20 at 12:01 P.M. revealed LPN #30 completed a finger stick blood glucose (FSBG) on Resident #12 inside resident's room. LPN #30 verified Resident #12 was on quarantine and droplet precautions due to other residents on the same hallway testing positive for COVID-19. Observation revealed LPN #30 completed direct care for Resident #12 while wearing a KN95 respirator with ear loops secured behind her ears. Interview with LPN #30 verified she had a KN95 respirator in place while she provided direct care to Resident #12. LPN #30 stated she was not aware the KN95 respirator was not appropriate for COVID-19 quarantine unit. Review of the facility's list of residents for COVID-19 cases revealed Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 and #12 never tested positive for COVID-19 or who have recovered from COVID-19 at the time of the survey. Review of the product labeling boxes and package inserts for the KN95 respirators revealed the respirators were labeled and indicated for non-medical use. The package inserts revealed no evidence the KN95 respirators were appropriate to be worn on a COVID-19 unit and /or to effective against COVID-19. Review of the facility's policy titled COVID-19 Guidelines for PPE, dated 10/26/20, revealed any staff member that provided direct resident care in the red zone (COVID-19 unit) was required to wear a NIOSH certified N95 or higher-level respirator. It also stated any staff member that provided direct resident care in the yellow zone (COVID-19 quarantine unit) was required to wear a NIOSH certified N95 or higher-level respirator. Review of the Centers for Medicare and Medicaid Services (CMS) memo titled Nursing Home Guidance, dated 04/02/20, revealed all nursing homes shall ensure they are complying with all CMS and CDC guidance related to infection control. Review of the CDC guidelines at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html., revealed Health Care Professionals (HCP) working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with [DIAGNOSES REDACTED]-CoV-2 infection. Staff should also wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters and wear an N95 or equivalent or higher-level respirator, instead of a facemask. Guidelines revealed PPE for health care personnel (HCP) who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to standard precautions and use a (National Institute Occupational Safety and Health) (NIOSH) approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. Review of the CDC's website titled Counterfeit Respirators/ Misrepresentation of NIOSH - Approval, last updated 01/05/21, revealed signs that a respirator may be counterfeit include the filtering facepiece respirator has ear loops instead of headbands, no approval (TC) number on filtering facepiece respirator or headband, and no NIOSH markings. It further stated NIOSH-approved N95 respirators that also have been cleared by the FDA are recommended for use by healthcare professional who need protection from both airborne and fluid hazards.

Based on personnel file review, medical record review, observation, staff interview and facilty policy review, the facility failed to follow their [MEDICAL CONDITION] control plan when a new employee, a Dietary Services Assistant (DSA) #9 of six reviewed did not receive a two step Mantoux (PPD) test. This had the potential to affect all 45 residents of the facility. Additionally, the facility failed to ensure oxygen tubing was labeled and kept in a sanitary manner. This affected one resident (#37) of 16 reveiwed for oxygen therapy. Findings include: 1. Review of DSA #9's personnel file revealed a hire date of 05/02/19. There was no evidence the DSA received a two step [MEDICAL CONDITION] skin test (PPD) being completed. Interview with Corporate Support #300 on 07/03/19 at 2:09 P.M., verified DSA #9 did not have a two step PPD test completed prior to 07/03/19. Corporate Support #300 confirmed Dietary Services Assistant #9 was hired on 05/02/19. Review of the facility's policy Guidelines for [MEDICAL CONDITION] Results Summary Documentation dated 05/11/16 revealed upon hire each employee shall receive a two step Mantoux PPD test to ensure they are free from [MEDICAL CONDITION]. 2. Medical record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED].M. to 7:00 A.M., and to change the oxygen tubing once monthly. Observation with Licensed Practical Nurse (LPN) #57 of Resident #37 on 07/01/19 at 10:10 A.M., revealed the oxygen tubing was not labeled with the date it was initiated, and the tubing was observed laying directly on the floor. LPN #57 confirmed the oxygen tubing for Resident #37 was uncovered and observed laying directly on the floor. LPN #57 further confirmed the tubing should be labeled with the date it was initiated and it should not be stored in direct contact with the floor. Review of policy titled Guidelines for the Administration of Oxygen dated 09/17/18 revealed oxygen tubing should be changed monthly, as needed, and should be labeled with the date it was initiated.

Based on record review, staff and resident interviews, and review of a Self-Reported Incident (SRI), the facility failed to follow interventions to utilize two staff members when turning a resident. This resulted in actual harm when Resident #58 suffered avoidable pain and bruising caused by only one staff member being used to turn the resident and pulling unnecessarily on his arm. A total of three resident records were reviewed. This affected one of three sampled residents. The census was 70. Findings Include: Review of the medical record for Resident #58 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated on 01/20/17, revealed Resident #58 had impaired cognition and required extensive assistance of two staff with bed mobility. Review of the current plan of care noted Resident #58 required two staff to assist with all care, including bed mobility. Review of the SRI dated on 02/20/17 revealed the resident was receiving morning care/incontinent care from State tested Nurse Aide (STNA) #88. The resident complained of right arm pain after the STNA rolled him over in bed. The nurse was notified and the resident reported the STNA had injured him during care. The resident was tearful and shaky. Review of a statement in the SRI provided by STNA #88 revealed the resident had dried bowel movement on his buttocks. STNA #88 was providing care and requested the resident roll to his left side, which he did without difficulty. When STNA #88 asked him to roll to the right side the resident had difficulty and she could not clean him. STNA #88 stated she grabbed the resident by his arm and pulled him over. The resident yelled out in pain and yelled at to stop. STNA #88 went and got the nurse to help her transfer the resident from bed. STNA #88 indicated upon entering the room with the nurse the resident stated to the nurse he didn't want the STNA in the room. Review of a statement in the SRI, written by Licensed Practical Nurse (LPN) #77, revealed when she entered the room Resident #58 was visibly shaken. The resident was crying and guarding his arm he pointed at STNA# 88 and said she hurt his arm on purpose and he did not want her back in his room. Licensed Practical Nurse (LPN) #77 revealed she asked STNA #88 to leave Resident #58's room and send a therapist in to assist the nurse with the transfer. The resident was transferred into his wheelchair and continued to complain of pain in his right arm. The staff returned Resident #58 to bed due to his pain. The resident was noted to have bruising on the inner aspect of the right wrist. The statement revealed the physician was called and an order for [REDACTED]. The SRI indicated the X-ray results on 02/21/17 were negative for fracture. Review of SRI revealed a statement from Therapist #300 dated 02/22/17 which indicated he assisted LPN #77 to transfer Resident #58 on 02/20/17. The therapist's statement indicated the resident was crying the entire time. The SRI indicated on 02/22/17 Social Service Designee (SSD) #400 interviewed Resident #58. Resident #58 reported his arm was still sore. He reported the STNA had pulled his arm pretty hard. Review of the Skin Integrity Event form revealed an entry dated 02/21/17 at 10:30 A.M. revealed Resident #58 complained his arm hurt. Swelling was noted to the right elbow and an irregular shaped bruise was noted to the inside of the right wrist. The resident complained his arm had hurt since STNA #88 had provided care for him. Review of the progress notes dated 02/21/17 at 12:07 P.M. revealed Resident #58's arm was swollen, hot, red, and bruised. The doctor was notified and ordered an X-ray be obtained at the hospital. The X-ray was inconclusive for a fracture due to the swelling and Resident #58 returned to the facility with a splint in place. Review of the Skin Integrity Event form, dated 02/28/17 at 12:52 A.M., revealed Resident #58's right arm continued with bruising and swelling. Observation Resident #58 on 03/08/17 at 1:00 P.M. revealed he was sitting in his wheel chair in his room. The resident was holding his right arm. Interview on 03/08/17 at 1:00 P.M., Resident #58 stated his right arm hurt off and on. He stated he had limited blood flow to the right arm and it was very painful if it was bumped or touched. Interview with STNA #99 on 03/09/17 at 3:30 P.M. revealed Resident #58 required two people when turning side to side due to having pain in his right arm. Interview with the Administrator on 03/09/17 at 1:20 P.M. verified STNA #88 had used an improper technique and did not have two staff assistance when providing care to Resident #58. As a result of this STNA #88's employment was terminated. This deficiency substantiates Complaint Number OH 845.

Based on closed medical record review, observation, staff interview, review of fall circumstance investigations, and review of facility fall management program guidelines, the facility failed to provide adequate supervision to prevent falls. This resulted in Immediate Jeopardy for one (#80) of six sampled residents when the facility staff left confused, dependent Resident #80 unsupervised in a reclined lounge chair. The resident fell from the chair and sustained a large right subdural hematoma and subsequently died . The facility identified five current residents (#4, #28, #37, #65 and #81) requiring increased supervision due to their fall risks. The facility census was 68. On [DATE] at 12:30 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 12:15 P.M. when Resident #80 was left unsupervised, seated in a reclined lounge chair in the 100 unit lounge, next to the nurse's station. The resident was found lying on the floor at 12:20 P.M. with a laceration to her right eyebrow and blood pooling on the floor around the resident's head. Immediately after being found on the floor, Resident #80 was sent to the hospital where she was assessed as having sustained a large right subdural hematoma and subsequently died on [DATE]. The Immediate Jeopardy was removed on [DATE] at 12:25 P.M. when Resident #80 was transferred to the hospital. No other residents at the facility were identified as requiring intensive supervision needs. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected [DATE] when the facility implemented the following corrective actions: ? On [DATE], the DON and Assistant Director of Nursing (ADON) initiated an investigation of Resident #80's fall, reviewed fall documentation and completed continuous quality improvement rounds for residents identified at risk for falls. ? On [DATE], the DON and ADON reviewed the clinical records of residents identified to require "heavy care", at risk for falls, with a history of falls, with medically complex [DIAGNOSES REDACTED].#37, #65, #68 and #81). As of [DATE], no residents with similar needs as Resident #80 were identified residing in the facility. ? On [DATE], the DON and clinical team, in coordination with therapy, reviewed, reassessed and updated, interventions of all residents identified at high risk for falls. Care plans were also reviewed and updated as necessary. ? On [DATE], the DON and/or designee provided an in-service to nursing and therapy staff on facility fall management education information, and guidelines on Safety/Fall Management. ? On [DATE] interviews with Licensed Practical Nurse (LPN) #4 at 4:20 P.M., State tested Nurse Aide (STNA) #9 at 4:30 P.M. and STNA #10 at 4:37 P.M., confirmed knowledge of the facility's fall management education information, and information regarding resident assistance devices and accident supervision. ? On [DATE] two additional residents (#1 and #40) identified as being at high risk for falls were observed and their medical records reviewed. The residents were receiving the appropriate assistance devices and level of supervision for fall prevention per their written plan of care. ? Facility documentation dated [DATE], stated if the assessment of the resident, including fall history, observation/physical assessment of resident, resident/family interview, and/or staff communication indicated a need for one to one care, the campus would provide and implement this intervention. The campus would continue to provide ongoing assessment of the resident's response to this care plan intervention and provide appropriate alterations in the plan based on the resident's response. Findings include: Review of the closed clinical record of Resident #80 revealed the resident was initially admitted to the facility on [DATE] at approximately 4:45 P.M. from the hospital after a fall at home and fracturing her right wrist. Resident #80 was admitted with [DIAGNOSES REDACTED]. Nurse's notes, dated [DATE] at 5:25 P.M. by LPN #7, documented an alarm was added to the resident's bed and chair as the resident tried to get up without assistance. The nurse's notes did not indicate the resident's required level of supervision. Review of an Assessment and Review and Considerations form dated [DATE] revealed the resident was identified with fall risk factors of cognitive impairment and history of falls. Review of the Nursing Admission Assessment and Data Collection document dated [DATE], revealed no indication of the resident's level of required supervision regarding her safety. Nurse's notes by LPN #4 dated [DATE] at 10:00 A.M., documented the resident was continuously attempting to get out of her wheelchair to ambulate without staff assistance, and the pressure sensitive alarm was in place and functioning. Nurse's notes dated [DATE] at 2:00 P.M. stated Resident #80 was seated in a recliner chair in front of the nurse's station with the pressure sensitive alarm in place. Nurse's notes by LPN #8 dated [DATE] at 7:20 P.M. documented Resident #80 attempted to ambulate without assistance, tried to sit back down and missed the wheelchair and fell to the floor. Resident #80 sustained a small cut to the back of her head with heavy bleeding and was sent to the hospital where she received two staples. The resident returned to the facility on [DATE] at 1:45 A.M. Review of a fall/injury care plan dated [DATE] revealed the resident was identified at risk for falls due to a history of falls and receiving an anti-anxiety medication. There was no change in the resident's fall prevention interventions including her required level of supervision. Nurse's notes dated [DATE] at 9:30 A.M. revealed Resident #80 was trying to get out of the chair. The notes stated one on one with both the nurse aides was attempted and the resident was still trying to get out of the chair. On [DATE], LPN #7 completed a Change in Condition form regarding the resident's increase in behavioral issues. LPN #7 documented the resident was restless all the time, continuously tried to get out of the chair, was at high risk for falls, continuously leaned forward in her wheelchair and had an alarm in place. There was no documentation of concerns regarding the resident's supervision care needs in response to her increased behavior issues and fall risk. The comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had short and long term memory problems, was severely cognitively impaired and had inattention and hallucinations. The assessment further indicated Resident #80 required assistance of two staff persons for bed mobility and transfers and had a history of [REDACTED]. The resident's comprehensive plan of care for falls dated [DATE], stated the resident had a history of [REDACTED]. The care planned interventions included to provide/monitor the resident's use of adaptive devices including wheelchair, remind resident and reinforce safety awareness, bed and chair alarms, monitor at nurse's station during periods of restlessness and anxiety, involve resident in activities as tolerated, and lay down for naps as desired. The prevention care plan did not include the use of a reclined lounge chair, did not specify what type of bed and chair alarm were to be utilized and did not specify the level of supervision the resident required. Nurse's notes by LPN #8 dated [DATE] at 11:15 P.M., revealed Resident #80 climbed out of the bed onto her knees. Resident #80 was assisted back to bed three times. LPN #8 documented the "State tested nurse aide (STNA) gets the resident up, as she is restless and needs closer monitoring." Review of the facility fall circumstance investigation completed for the [DATE] fall revealed the prevention update section revealed Resident #80 was placed at the nurse's station, offered a snack, was given routine pain medications and an anti-anxiety medication, Lorazepam, due to restlessness. According to the circumstance investigation there was no indication the facility's Interdisciplinary Team (IDT) reviewed the fall prevention interventions to ensure they were appropriate to maximize the resident's safety. Further review of Resident #80's medical record revealed a fall circumstance investigation dated [DATE], for a fall that occurred at 12:20 P.M. The investigation noted LPN #4 was walking past the 100 unit lounge, near the nurse's station, and saw Resident #80 lying on the floor. The resident had a laceration to her right brow and was moaning and grimacing. According to the investigation, at the time of the fall the resident had been seated in a reclined lounge chair near the nurse's station and had tried to transfer herself. The resident was sent out 911 to the hospital. The resident's physician ordered medications at the time of the fall on [DATE] which included Coumadin (anticoagulant) and aspirin medications. During interview on [DATE] at 12:44 P.M., STNA #3 verified she was assigned to the 100 unit where Resident #80 was at the time of the fall on [DATE]. STNA #3 stated the staff really had to watch Resident #80 due to her wiggling all the time and continually moving. She stated the daily routine was to transfer the resident out of the wheelchair to the recliner chair in the lounge area near the nurse's station. She stated the resident could scoot to the edge of the seat in the wheelchair but could not in the recliner. STNA #3 stated the resident's pressure sensitive alarm was transferred to the seat of the recliner along with the resident. STNA #3 stated she left Resident #80 seated in the lounge area in the recliner with her feet up about 12:15 P.M. on [DATE]. STNA #3 stated when she came out of another resident's room she saw Resident #80 lying on the floor on her right side and LPN #4 on her knees next to the resident. STNA #3 stated LPN #5 was assigned to the 100 unit and half of the 200 unit and was passing medications and providing care to residents at the time of the fall. She stated STNA #6 was also assigned to the 100 unit and was transporting residents from the main dining room back to the 100 unit at the time of the fall. Interview with LPN #4 on [DATE] at 1:18 P.M., revealed she was assigned to the 300 hall and half of the 200 hall during the day shift on [DATE]. LPN #4 stated she was going from the 300 hall to the 200 hall when she saw Resident #80 lying on the floor next to the recliner. LPN #4 stated the resident was moving, that the pressure sensitive alarm in the chair was not sounding and the chair was reclined back at that time. LPN #4 stated the resident was mumbling and trying to lift her head and there was a puddle of blood on the floor. LPN #4 stated she noted a laceration to the resident's right eyebrow and applied pressure. She stated she called for LPN #5, who called 911 while she continued to apply pressure to the resident's brow laceration. LPN #4 stated emergency services arrived within a couple of minutes and transported Resident #80 to the hospital. LPN #4 stated the pressure sensitive alarm under the resident in the recliner didn't work until it was removed from the recliner because the pad was caught between the back and seat of the chair causing pressure to be applied. LPN #4 stated the resident did not have a plan of care for one on one supervision, however, she and other staff had provided one on one supervision due to the resident's behaviors of continually trying to get up. LPN #4 stated she and other nursing staff tried to provide as much one on one supervision of the resident as was possible. During interview on [DATE] at 2:55 P.M., LPN #5 verified she was assigned to the 100 hall on [DATE] when Resident #80 fell . She stated the resident had been very agitated and removed her clothing in the morning and she had given her Lorazepam at 8:15 A.M., and a routine narcotic analgesic at 11:30 A.M. LPN #5 stated she sat down at the nurse's station near where Resident #80 was seated in the recliner in the lounge. LPN #5 stated she left the nurse's station to administer medication to a resident on the 200 hall and was not on the unit at the time Resident #80 fell from the recliner. LPN #5 stated when she saw Resident #80 on the floor LPN #4 was already with the resident applying pressure to the resident's head. LPN #5 stated she called 911 and then took the resident's vital signs while LPN #4 continued to apply pressure. She stated the resident died at the hospital the next day. LPN #5 stated Resident #80 needed constant supervision. Interview on [DATE] at 3:07 P.M. with LPN #8, the nurse on duty at the time of the resident's fall on [DATE], verified the resident was confused, had very poor balance and needed physical assistance of two staff to safely stand and transfer from one surface to another. LPN #8 stated after the resident's fall on [DATE], it was understood amongst staff that cared for Resident #80, they needed to keep their "eyes on her." He stated he tried to keep the resident within arm's reach, as she could fall quickly. LPN #8 stated at times he would take Resident #80 along with him while he passed medications to other residents so that he could reach her right away if she tried to get up unassisted. Interview with STNA #6 on [DATE] at 10:10 A.M., revealed she last saw Resident #80 prior to her falling as she was transporting residents back from the main dining room to the unit on [DATE] after lunch between 12:00 P.M. to 12:15 P.M. STNA #6 stated she observed Resident #80 seated in the reclined lounge chair in the 100 unit lounge, in front of the nurse's station. She stated the resident was very restless and was putting her legs over the side of the chair. STNA #6 stated the resident "was bound and determined to get out of the chair." STNA #6 stated she repositioned Resident #80 properly in the recliner and then returned to the main dining room to transport another resident back to the unit. She stated at the time she repositioned the resident, LPN #5 was not on the unit and STNA #3 was assisting a resident in that resident's room. No other staff were present. Review of the facility's undated Fall/Safety Management Educational Information, revealed if a resident fell , staff were to complete an investigation of the circumstances surrounding the fall to determine the cause of the episode, an assessment of contributing factors, reassess possible contributing factors, develop interventions to reduce risk of repeat episodes and a review by the interdisciplinary team (IDT) to evaluate thoroughness of the investigation and appropriateness of the interventions. This certification deficiency substantiates Master Complaint Number OH 068 and Complaint Number OH 946.