Every finding on record at Trueman Pointe Care Center

Based on observation, medical record review, and staff interview, the facility failed to attempted non-pharmacological interventions for resident behaviors prior to administering as-needed psychotropic medications. This affected one (Resident #10) of five residents reviewed for antipsychotic medication administration. The facility census was 63.Findings include:Review of Resident #10's medical record revealed an admission date of 02/25/26 with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbance; depression; unspecified psychosis not due to a substance or known physiological condition; and metabolic encephalopathy.Review of Resident #10's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she had severely impaired cognition.Review of Resident #10's plan of care dated 03/06/26 revealed she was at risk for adverse effects related to psychoactive medication use due to dementia with behaviors and depression. Interventions included to give medications as ordered, utilize as needed medications only after non-drug measures were ineffective, and report to the physician any negative outcomes associated with the use of psychoactive drug.Review of Resident #10's physician order dated 03/19/26 revealed an order for lorazepam (anti-anxiety medication) two (2) milligrams (mg) per milliliter (ml) oral concentrate with instructions to give 0.25 ml every one hour as needed for anxiety/restlessness.Review of Resident #10's medication administration record (MAR) for March 2026 revealed lorazepam was administered once on 03/14/26, 03/16/26, 03/21/26, 03/24/26, 03/26/26, and 03/29/26 and twice on 03/19/26 and 03/23/26.Review of Resident #10's MAR for April 2026 revealed lorazepam was administered once on 04/12/26, 04/13/26 and 04/19/26.Review of Resident #10's May 2026 MAR revealed lorazepam was administered once on 05/05/26 and 05/06/26.Further review of Resident #10's MARs for March through May 2026 revealed no non-pharmacological interventions were provided prior to administering as needed lorazepam on 03/14/26, 03/16/26, 03/19/26, 03/21/26, 03/23/26, 03/24/26, 03/26/26, 03/29/26, 04/12/26, 04/13/26, 04/19/26, 05/05/26, and 05/06/26.Interview and observation on 05/19/26 at 12:00 P.M. with Registered Nurse (RN) #216 revealed if a resident had an as needed psychotropic medication there was usually supplementary documentation to add for non-pharmacological interventions. At the time of the interview, an observation revealed a laminated sheet on top of the medication cart with the numbers correlating with the different interventions. Interview on 05/19/26 at 2:06 P.M. with the Director of Nursing (DON) verified no non-pharmacological interventions were provided prior to administering the as needed lorazepam to Resident #10 for the above mentioned dates in March, April, and May 2026. Interview on 05/20/26 at 11:30 A.M. with the Administrator revealed the behavior documentation and non-pharmacological interventions are documented by the certified nurse aides (CNAs) and not by the nurse administering the medication.

Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure residents were assessed for the use of a physical restraint. This affected two (#23 and #41) of two residents reviewed for physical restraints. The facility census was 63.Findings include:1. Review of the medical record for Resident #23 revealed an admission date of 12/23/22 with diagnoses including type two diabetes mellitus with diabetic chronic kidney disease, schizophrenia, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and bipolar disorder.Review of Resident #23's most recent comprehensive Minimum Data Set (MDS) assessment, dated 03/22/26, revealed Resident #23 had severely impaired cognition and had no impairments to bilateral upper and lower extremities. She required partial/moderate assistance with transfer and substantial/maximal assistance with ambulation.Review of the medical record for Resident #23 revealed a physician order dated 03/27/24 for a pressure sensor alarm (PSA) to the chair and an order dated 03/31/23 for a sensor pad alarm to the bed.Review of Resident #23's fall care plan dated 08/18/25 revealed Resident #23 was at risk for falls, had history of falls non-compliance, history of removing alarms and impaired cognition. Interventions included keeping the bed against wall to provide more space in the room, a mattress with raised perimeters, and a pressure sensor alarm to the bed and a pressure sensor alarm to the wheelchair.Further review of Resident #23's medical record revealed restraint-enabler decision tree assessments dated 11/26/25, 03/04/26, and 04/09/26. No assessment indicated the sensor alarms to the bed or chair were evaluated as a restraint.Review of the medical record for Resident #23 revealed no documentation to support the facility completed restraint assessments for the use of the alarms to the bed and chair.Observation on 05/19/26 at 2:40 P.M. and 05/20/26 at 9:30 A.M. and 11:39 A.M. revealed Resident #23 in a wheelchair with a PSA to the bed and wheelchair.Interview on 05/20/26 at 4:00 P.M., with the Administrator confirmed the facility had not completed restraint use assessments for Resident #23 for the use of alarms to bed and chair.2. Review of the medical record for Resident #41 revealed an admission date of 09/03/24 with diagnoses including type two diabetes mellitus with diabetic neuropathy, unspecified dementia, with other behavioral disturbance, schizoaffective disorder, bipolar disorder, anxiety disorder, unspecified convulsions, and nicotine dependence.Review of Resident #41's most recent MDS assessment, dated 04/07/26, revealed Resident #41 had moderate impaired cognition and had no impairments to bilateral upper and lower extremities. She required supervision/touching assistance with transfers and ambulation. The MDS assessment revealed she did not have any falls and a chair and bed alarm was identified on the assessment.Review of the medical record for Resident #41 revealed a physician order dated 02/23/25 for a PSA to the chair and bed.Review of Resident #41's fall care plan dated 10/14/24 revealed Resident #41 was at risk for falls, had dementia, impaired cognition, history of falls and non-compliance with interventions. Interventions included keeping the bed in the lowest position, encourage the resident to use a rollator rather than her cane with mobility, and ambulate with assistance and gait belt in place.Further review of Resident #41's medical record revealed restraint-enabler decision tree assessments dated 08/11/25, 11/11/25, and 03/31/26. No assessment indicated the sensor alarms to the bed or chair were evaluated as a restraint.Review of the medical record for Resident #41 revealed no documentation to support the facility completed restraint assessments for the use of the alarms to the bed and the chair.Observation on 05/17/26 at 10:00 A.M. and 3:00 P.M. revealed Resident #41 was in a wheelchair with a PSA to the bed and wheelchair.Interview on 05/20/26 at 4:00 P.M. with the Administrator confirmed the facility had not completed restraint use assessments for Resident #41 for the use of alarms to her bed and chair. The Administrator stated the alarms were discontinued on 05/18/26 due to a review and the resident had not had any falls.Review of facility policy titled, Restraint Use, dated 06/20/15, revealed the facility creates and maintains an environment that fosters minimal use of restraints. Alternatives to restraint use may include scheduled ambulation, diversional activities, scheduled exercise, use of a lounge chair and positioning devices such as pillows, cushions, bolsters, and lap belts or trays that the resident is able to self-release. A restraint assessment shall be used for initial and ongoing assessments.

Based on observation, staff interview, and medical record review, the facility failed to ensure medications were properly stored. This affected one (#61) of one residents reviewed for medication storage. The facility census was 63.Findings include:Review of the medical record for Resident #61 revealed an admission date of 03/05/24 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, unspecified convulsions, unspecified glaucoma, and chronic pain syndrome.Review of Resident #61's care plan dated 03/26/24 revealed the resident was at risk for alteration in comfort related to chronic pain syndrome, arthritis, general pain, and chronic back pain. Interventions included to administer medications as ordered.Review of Resident #61's physician's orders revealed an order dated 04/21/26 for gabapentin (medication used for seizures or as an analgesic) 400 milligrams (mg) with instructions to give one pill by mouth every eight hours for neuropathy. Resident #61 had no orders to self-administer medications or for medications to be left at the bedside.Observation on 05/17/26 at 11:05 A.M. revealed one capsule in a cup on Resident #61's bedside table.Interview and interview on 05/17/26 at 11:05 A.M. with Licensed Practical Nurse (LPN) # 212 revealed she did not administer Resident #61 the medication in the morning indicating night shift nurses administer the medication, and stated the capsule appeared to be the resident's gabapentin. LPN #212 verified Resident #61 did not have an order for self-administration or for medications to be left at bedside.Interview on 05/22/26 at 11:30 A.M. with the Administrator revealed the facility did not have a policy for medication storage or medication administration.

Based on medical record review, staff interview, and policy review, the facility failed to ensure resident medical records were complete and accurate. This affected three (#2, #9, and #65) residents of 24 residents reviewed for documentation accuracy. The facility census was 63.Findings include:1. Review of the medical record for Resident #2 revealed an admission date of 04/02/24 with diagnoses including type one diabetes with diabetic neuropathy, acute chronic respiratory failure, and chronic kidney disease stage three. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had mild cognitive impairment, had adequate vision without devices, and was independently mobile using a manual wheelchair. Review of Resident #2's admitting diagnoses dated 04/03/24 included type one diabetes mellitus with diabetic neuropathy, unspecified (T1D).Review of multiple pulmonology progress notes listed T1D in Resident #2's active diagnoses.Review of multiple physician and nurse practitioner notes listed type two diabetes mellitus without complications (T2D) in Resident #2's active diagnoses. The diagnosis was not listed anywhere else in Resident #2's medical record.Interview on 05/19/26 at 2:06 P.M. with Director of Nursing (DON) #283 confirmed she did not know which diagnosis of diabetes was correct for Resident #2. At 4:13 P.M., DON #283 stated Resident #2 admitted with a diagnosis of T1D but endocrinology notes listed T2D. DON #283 confirmed T2D would be added to Resident #2's list of active diagnoses. DON #283 could not confirm which diagnosis was correct.Review of the medical record on 05/20/26 at 12:31 P.M. of Resident #2's active diagnoses revealed the addition of T2D. The diagnosis for T1D was still active and remained the primary diagnosis.Interview on 05/20/26 at 2:22 P.M. with DON #283 revealed she provided admission documentation time-stamped 03/27/24 included a diagnosis of T1D and an after visit summary dated 08/21/24 from an endocrinology appointment which included T2D with stage 3a chronic kidney disease, diabetic polyneuropathy, bilateral moderate non-proliferative retinopathy, and diabetic autonomic neuropathy. DON #283 was unable to verify which diagnosis was correct.2. Review of the medical record for Resident #9 revealed an admission date of 04/26/22 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, chronic pain syndrome, and chronic kidney disease stage one. Review of the annual MDS assessment dated [DATE] revealed Resident #9 was cognitively intact and was dependent on staff assistance for bathing, bed positioning, and mobility. Continued review of the MDS assessment revealed Resident #9 was at risk for skin breakdown, had no unhealed pressure ulcers, no unhealed venous or arterial ulcers, and no other skin conditions.Review of physician's orders date 09/17/25 revealed Resident #9 was to have a head-to-toe skin check completed weekly on the Saturday night shift.Review of the accident and incident log from 05/18/25 to 05/18/26 revealed Resident #9 a red area incident identified on 04/28/26 at 8:00 P.M.Review of the initial Skin Grid - Non-Pressure assessment dated [DATE] revealed a bruise to the outside of Resident #9's left leg two (2) centimeters (cm) long by 2 cm wide by 0.0 cm deep without odor or drainage.Review of the as needed Skin Grid - Non-Pressure assessment dated [DATE] revealed the wound had been recategorized as an abrasion. Further assessment of the wound revealed it was reported as healed on 05/19/26.Review of the treatment administration record (TAR) for May 2026 revealed Resident #9 had head-to-toe skin checks completed on 05/02/26, 05/09/26, and 05/16/26.Review of the progress note dated 04/29/26 (entered on 04/30/26) noted an area of concern to the outside of Resident #9's left leg. Assessment with the nurse practitioner identified the area as shearing. Further review of progress notes revealed no other notes related to this skin injury or of the findings of the weekly head to toe skin checks. Interview on 05/20/26 at 1:27 P.M. with DON #283 confirmed Resident #9 had orders for weekly head-to-toe skin assessments. DON #283 confirmed the nurse completing the skin checks should mark it as complete on the TAR and the nurse should document findings. DON #283 confirmed the skin checks were marked as complete on the TAR and confirmed there were no notes in the chart reporting the findings from the assessments. Review of the policy titled, Skin Assessment, revised on 03/15/24, stated an assessment of a resident's alteration(s) of skin integrity shall be performed and recorded in the resident's medical record at least weekly.3. Review of the medical record for Resident #65 revealed an admission date of 02/11/26 with diagnoses including chronic respiratory failure with hypoxia, type two diabetes with diabetic neuropathy, and chronic peripheral venous insufficiency. Review of the MDS assessment date 03/25/26 revealed Resident #65 was cognitively intact and was dependent on staff assistance for bathing, toileting, and bed positioning. Further review of the MDS assessment revealed Resident #65 was at risk for skin breakdown and did not have any unhealed pressure ulcers, venous or arterial ulcers, or other skin conditions at the time of the assessment.Review of progress notes revealed Resident #65 had a hospitalization from 04/09/26 to 04/14/26 for altered mental status, urinary retention, and acute kidney injury with chronic kidney disease. While in the hospital, Resident #65 was evaluated by the wound care team for a pressure ulcer on his right heel. Resident #65 was found to have a stage three pressure ulcer (full-thickness skin loss) on the right heel originally identified on 01/05/26. A red area was also noted to Resident #65's sacrum and scabbed vascular ulcers to both lower legs. Review of the re-admission nursing note date 04/14/26 at 3:41 P.M. revealed Resident #65 returned to the facility from the hospital. A head-to-toe skin assessment was completed with findings including no open wounds but redness noted to the scrotum.Review of Resident #65's skilled progress note date 04/14/26 at 10:29 P.M. revealed a skin assessment was completed without any changes.Review of Resident #65's Skin Assessment Admission/readmission assessment completed on 04/14/26, completed by Licensed Practical Nurse (LPN) #236, revealed no pressure or non-pressure ulcers were present. Further review revealed identification of a pressure ulcer/injury on the mucosal membrane labeled Wound #1 and measuring one (1) cm long by 1 cm wide by 0.2 cm deep. There were no other descriptors of the wound and there were no other wounds or skin concerns noted in the assessment.Review of Resident #65's Skin Grid - Pressure assessment date 04/15/26 revealed Wound #1 had been updated to an unstageable pressure ulcer (obscured full-thickness skin and tissue loss) that was present on admission and measured 1 cm long by 1 cm wide by 0.2 cm deep.Review of the physician progress note dated 04/16/26 revealed Resident #65 had a stage three pressure ulcer and sacral contact dermatitis. Interview on 05/20/26 at 2:13 P.M. with LPN #236 confirmed she completed Resident #65's readmission assessment. LPN #236 confirmed Resident #65 had no skin issues present upon readmission on [DATE].Interview on 05/20/26 at 3:18 PM with Assistant Director of Nursing (ADON) #209 confirmed Resident #65's skin assessment completed upon readmission on [DATE] did not match the nursing progress notes of the same date.

Based on record review and staff interview, the facility failed to ensure Resident #56 received adequate assistance to prevent a fall from bed while care was being provided. This affected one (Resident #56) of three residents reviewed for falls. The facility census was 63. Findings include: Review of the medical record revealed Resident #56 was readmitted to the facility on [DATE] with diagnoses including cerebral infarction, type II diabetes mellitus, aphasia, retention of urine, and encephalopathy. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had cognitive impairment. Resident #56 had impairment to one side and required substantial to maximal assistance for turning. Review of the State tested Nursing Assistant (STNA) documentation for bed mobility revealed Resident #56 required extensive to total dependence of staff to turn side to side with the assistance of one to two staff. A health status note dated 09/03/24 at 11:00 P.M. revealed Resident #56 slid out of the right side of the bed during care. STNA #107 had rolled Resident #56 to the right side to wash Resident #56's back during a bed bath. Resident #56 sustained a one centimeter skin tear to the left ear. A fall investigation dated 09/03/24 at 11:00 P.M. revealed Resident #56 had no previous falls and Resident #56 slid to the floor during care. Resident #56 was rolled to the right side during a bed bath and rolled out of bed. A new intervention was to make sure Resident #56 was centered in the bed. A written statement dated 09/03/24 by STNA #107 revealed Resident #56 fell out of bed while STNA #107 was giving Resident #56 a bed bath. STNA #107 washed Resident #56's back and while drying Resident #56's back, Resident #56 rolled out of the bed. The incident occurred around 10:35 P.M. Interview on 09/17/24 at 11:30 A.M. with Director of Nursing (DON) verified Resident #56 fell from bed while care was being provided.

Based on review of thee facility policy, observations, resident and staff interview, and record review, the facility failed to ensure residents did not receive foods against their dietary preferences and allergies. This affected one (Resident #34) of one resident reviewed for food preferences. The Facility census was 63. Finding include: Review of the medical record for Resident #34 revealed an admitted [DATE]. Diagnoses included respiratory failure, lymphedema, and heart disease. Review of the physician orders dated 04/19/24 revealed Resident #34 had an order for mechanical soft diet with thin consistency, allergies of strawberries and pineapples, with a no added salt and large protein portions. Review of lunch meal ticket dated 09/17/24 revealed Resident #34 had pineapple listed under dislikes and also had it identified in two spots on the meal ticket as well as strawberries. Interview and observation on 09/17/24 around 11:50 A.M. with Kitchen Staff #144 revealed regular diets received melon, mechanical soft received crushed pineapple, and puree diet received puree pineapple. Kitchen Staff #144 revealed mechanical soft and puree diets were unable to have melon. It was observed Kitchen Staff #144 placed mechanical soft pineapple on Resident #34's tray along with the ticket that included a dislike for pineapple and allergy to pineapple. Observation and interview on 09/17/24 at 12:50 P.M. with Resident #34 revealed she was served crushed pineapple as her lunch dessert. Resident #34 stated she was allergic to pineapple and strawberries and she frequently received these items on her tray. Resident #34 showed her meal ticket which displayed pineapple as a dislike and also as an allergy twice. Interview and observation on 09/17/24 at 12:55 P.M. with Registered Nurse (RN) #163 confirmed Resident #34 received crushed pineapple and also confirmed it stated she had an allergy to this item on her tray ticket. RN #163 left the pineapple on her tray and exited the room. Interview on 09/18/24 at 2:00 P.M. with Diet Technician #180 verified Resident #34 should not have been given pineapple unless requested as melon can be chopped and pureed. She also verified resident's tray tickets shall be reviewed when doing tray line to monitor for likes, dislikes and allergies. Review of the menu spreadsheet for lunch meal on 09/17/24 revealed mechanical soft diet should have also received diced melon and puree diets should receive pureed melon. Review of the facility policy titled Religious, Ethnic, and Cultural Food Preferences dated 08/07/14 revealed food preferences shall be accommodated by the facility. Resident food allergies shall be included on the diet order form.

Based on interviews and medical record review, the facility failed to implement orders for a pressure ulcer treatment affecting one resident (#10) of three residents reviewed. The facility census was 68. Findings include: Review of the medical record for Resident #10, revealed an admitted [DATE]. Diagnoses included but were not limited to spastic quadriplegic cerebral palsy, acute and chronic respiratory failure with hypoxia, unspecified mood disorder, and dependence on a respirator (ventilator) status. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 13 out of 15 indicating cognitive intactness. The resident was assessed to require total dependence on all aspects of care. Review of the active care plan for Resident #10 revealed an alteration in skin integrity as evidenced by pressure ulcer present at the left gluteal fold with interventions including but not limited to body check weekly and as needed, provide treatment per physician orders and to assess condition of skin/dressing. Review of Resident #10's record revealed a skin grid pressure discovered on 04/17/24 and was a stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer to the left gluteal fold that measured 3.5 centimeters (cm) X 7 cm X. 1 cm. Review of the Wound Nurse Practitioner (NP) visit note dated 04/17/24 for Resident #10 revealed a new pressure wound; stage 3 pressure ulcer to the left gluteal fold that measured 3.5 centimeters (cm) X 7 cm X. 1 cm. Patient plan and order to apply a foam dressing to insulate, pad and protect, to be changed daily was noted. Review of Resident #10's physician orders revealed no dressing change order placed for the left gluteal fold stage 3 pressure ulcer until 04/23/24 and no order to evaluate and assess the pressure area dressing until 04/24/24. Review of Resident #10's Treatment Administration Record and progress notes revealed no documentation of a left gluteal fold stage 3 pressure ulcer dressing change daily as ordered by the Wound NP from 04/17/24 through 04/22/24. Interview on 07/31/24 at 1:24 P.M. with Licensed Practical Nurse (LPN) #444 revealed she is the nurse who does the wounds at the facility. Verified that when the Wound NP ordered a dressing change for the left gluteal fold on 04/17/24 the order was not placed into Resident #10's chart and no order for a dressing change was entered until 04/23/24, but she did complete the dressing changes even though there are no documentation of them being completed in the residents chart. The facility was unable to produce a policy on wound care for pressure ulcers. This deficiency represents non-compliance investigated under Master Complaint Number OH00155689 and Complaint Number OH00155383.

Based on medical record review, and resident and staff interviews, the facility failed to ensure a resident was transferred safely to prevent an avoidable fall with injury and the fall was not thoroughly investigated to determine the root cause analysis to identify potential hazards to reduce and/or eliminate falls with major injury. This resulted in Actual Harm when State tested Nurse Aide (STNA) #200 attempted to transfer Resident #04 from a wheelchair by lifting the resident by the trousers versus utilizing a gait belt, resulting in Resident #04 falling to the floor and suffering a proximal right fibular fracture just below the surgical equipment that was just placed two weeks prior. This affected one (#04) of three residents reviewed for falls. Facility census was 61. Findings include: Review of medical record for Resident #04 revealed an admitted [DATE] and re-admitted [DATE]. The resident had diagnoses including status post right knee arthroplasty, asthma, and diverticulosis. Review of the fall risk assessment dated [DATE] revealed Resident #04 was at risk for falls. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #04 was cognitively intact and required extensive assistance of one for bed mobility, transfer, and toilet use. Review of the plan of care dated 02/14/23 revealed the resident was at risk for falls. Interventions included bed in lowest position and encourage to ask for assistance. There was no interventions related to safe transfers. Review of a health status note dated 02/18/23 at 9:47 A.M., revealed Resident #04 returned from the hospital from a planned status post right total arthroplasty on 02/16/23. Resident #04 required one assist with wheeled walker while at the hospital. Review of a health status note dated 03/04/23 at 4:00 P.M., revealed STNA #200 notified Licensed Practical Nurse (LPN) #100, that Resident #04 had fallen. Resident #04 was sitting on her bottom with her right and left legs straight out. The left leg was observed partially under the bed. The wheelchair was directly behind the resident and the bedside commode was to the left of the wheelchair. STNA #200 stated when attempting to transfer Resident #04 from the wheelchair to bedside commode, STNA #200 attempted to stand Resident #04 up from behind by gripping the resident's trousers and lifting. Resident #04's legs became weak once she was in a standing position and fell to the floor. Resident #04 had no open areas or bruising. LPN #100 and another nurse used a gait belt and assisted the resident back into bed. Resident #04 immediately had complaints of pain to bilateral knees, left shoulder, and right wrist. Resident #04 was transferred to the hospital. Review of hospital after visit summary dated 03/04/23, revealed Resident #04 had a closed fracture of proximal end of right fibula from a fall. Resident #04 stated while trying to transfer back to bed, she fell , and hurt her left shoulder, left knee, right knee, right ankle, and right forearm/wrist area. Resident #04 was status post right knee arthroplasty two weeks ago. The right knee x-ray revealed a proximal right fibular fracture. The emergency department doctor discussed the fracture with the orthopedic surgeon due to the hardware was just above the fracture. Orthopedic was okay with boot and weight bearing as tolerated. Review of a health status note dated 03/04/23 at 11:56 P.M., revealed Resident #04 returned from the hospital with a fracture to the right knee. The resident had a brace to right lower leg and complained of pain. Review of the medical record revealed there was no evidence of a fall investigation or root cause analysis of the fall being completed to determine the cause of the fall. Interview on 03/09/23 at 9:23 A.M., with LPN #100 revealed she was working but was not in the room when Resident #04 fell . She provided verbal education to STNA #200 about proper transfer and assistance with transferring. Resident #04 had been transferring with one assist and may have just been tired and weak when she fell . Interview on 03/09/23 at 9:30 A.M., with Resident #04 verified STNA #200 tried to transfer her without a gait belt. Resident #04 was sitting in her room in a wheelchair and a leg brace was visible to the right leg. Resident #04 stated it felt like two fists in her lower back when the STNA (#200) was transferring her. Resident #04 stated she was upset and did not want to talk about the fall because now her insurance days at the facility would be up and she now had a cast on her leg due to the fracture. Resident #04 stated STNA #200 who assisted her was from outside (agency). Interview on 03/09/23 at 10:38 A.M., with Physical Therapy Assistant (PTA) #108 revealed Resident #04 had difficulty standing from a sitting position and required the assistance of one person. Interview on 03/09/23 at 11:50 A.M., with Rehabilitation Director #107 revealed Resident #04 was a one person assist for all activities of daily living. Resident #04 was a little weaker and had more pain after knee replacement but still required one person assistance for transfers. Interview on 03/09/23 at 3:23 P.M., with the Director of Nursing (DON) revealed there were gait belts in each resident room to be used when transferring residents. The DON verified standing behind a wheelchair and pulling on a resident's pants was not the correct way to transfer a resident. The DON verified the facility did not complete a fall investigation to identify how the resident was being transferred, what interventions needed to be put in place, or what caused the resident to fall. The DON stated the facility does not have a policy related to transferring a resident. This deficiency represents noncompliance discovered during the investigation of Complaint Number OH00139214.

Based on observations, medical record reviews, facilities isolation guidelines and infection control policies and staff interviews, the facility failed to ensure one of two residents (Resident #29) identified with an infection, was placed into contact isolation as required. The facility census was 54. Findings include: Review of Resident #29's medical records identified admission to the facility occurred on 12/29/21. Resident #29 had medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #29's urinalysis results dated 08/26/22 identified positive results that evidenced two different bacteria ([CONDITION(S)] pneumoniae and entercoccus Faecalis) were growing. The report also identified resistance markers included; ESBL (extended spectrum [NAME]-lactamase) which is a multi-drug resistant and can not be killed by many of the antibiotics available. Observation of Resident #29 and her room occurred on 08/29/22 at 11:08 A.M. and 08/30/22 at 7:52 A.M. Resident #29's room identified no evidence of any isolation precautions were in place (no signage on door and no equipment outside the door). Review of Resident #29 urinalysis results occurred with the facility Director of Nursing (DON) on 08/30/22 at 2:21 P.M. The review of the results confirmed the bacteria was positive for ESBL producing. The interview confirmed Resident #29 should be placed in contact isolation throughout her antibiotic treatment regimen. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility standard and transmission-based precautions policy, dated 11/28/17 identified specifies the different types of precautions, including when and how isolation should be used for a resident. The policy identified contact precautions are measures that are intended to prevent transmission of infectious agents, including epidemiological important microorganisms, which are spread by direct or indirect contact with the resident or the residents environment. Transmission-based precautions will be maintain as long as necessary to prevent the transmission of infection (while the risk of transmission of the infectious agent persists or for the duration of the illness). However should be the least restrictive possible and for the shortest amount of time. Review of the CDC guidelines, isolation precautions, provided from the facility regarding ESBL's infections- The recommendation identified Contact precautions. The [CONDITION(S)] judged by the infection control program, based on local, state and regional or national recommendations to be of clinical and epidemiologic significance. Contact Precautions recommended in setting with evidence of on-going transmission, acute care setting with increased transmission or wound that cannot be contained by dressing.

Based on resident and staff interviews, review of Facility Reported Incidents (FRI), record review and facility policy review, the facility failed to timely report an allegation of abuse for one resident (Resident #207). This affected one (Resident #207) of one residents reviewed for abuse. The facility census was 54. Findings Include: Review of the medical record for Resident #207 revealed an admitted on 08/06/22 and a discharge date on 08/30/22. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #207 had mildly impaired cognition and scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #207 required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs), including bed mobility. Review of the physician orders dated August 2022 revealed Resident #207 had an order dated 08/09/22 to encourage and/or assist to turn and reposition as tolerated every shift. Review of the plan of care dated 08/06/22 revealed Resident #207 experienced an alteration in mood and/or behavior that included yelling, screaming, refusing care, feeling bad about herself or feeling like a failure, feeling tired or having little energy, poor appetite, overeating, and often refused to get out of bed. Interventions included allow resident to vent, validate feelings as needed, attempt to identify what triggered behavior, find a staff member with a good rapport with the individual, and administer medications as ordered by the physician. Review of progress notes dated 08/29/22 revealed there was no documentation of any reported allegations of abuse. Interview on 08/29/22 at 2:16 P.M. with Resident #207 revealed an aide or nurse over the weekend was not very friendly toward her and refused to reposition her when the resident requested to be moved in the bed. Resident #207 stated she felt mistreated by the staff person over the weekend. Resident #207 described the staff person involved as an African American, heavyset female. Resident #207 stated she reported the incident this morning (08/29/22) to State tested Nurse Aide (STNA) #100. Resident #207 stated she had not received any follow up from the staff since reporting the incident this morning. Review of Facility Reported Incidents (FRIs) revealed there was no report of the allegation on 08/29/22. Interview on 08/31/22 at 10:33 A.M. with STNA #100 revealed the aide had worked at the facility for three years and worked on Resident #207's unit Monday through Friday during the day. STNA #100 confirmed Resident #207 informed her she did not feel the staff over the weekend treated her very nicely. STNA #100 confirmed Resident #207 reported the incident to her first thing in the morning on 08/29/22. STNA #100 stated Resident #207 reported the aide over the weekend was a little rough and didn't clean her up very well. STNA #100 stated she told Resident #207 that the aide's behavior was unacceptable and that the resident should definitely report the incident to the Administrator. STNA #100 stated she was pretty sure she also reported the incident to the Assistant Director of Nursing (ADON)/Unit Manager (UM) #60 within an hour of Resident #207 reporting it to her. Interview on 08/31/22 at 10:50 A.M. with UM #60 revealed she had been the UM on Resident #207's unit for a couple of weeks. UM #60 stated she had been in and out of the facility over the weekend and had not received any negative reports about the weekend staff from any of the residents. UM #60 stated she did not recall STNA #100 reporting any allegations of abuse or negative interactions that involved Resident #207 on 08/29/22. Interview on 08/31/22 at 4:42 P.M. with the Director of Nursing (DON) confirmed a FRI was just opened today (two days after the allegation had been reported to staff) once the administrative staff had been made aware of the allegation. Review of the facility policy, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16, revealed the policy stated, all incident and allegations of abuse, neglect, exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review, staff interview, and resident interview, the facility failed to administer one resident (Resident #23) [MEDICATION(S)] as ordered upon admission. This affected one (Resident #23) of six residents reviewed for medication administration. The facility census was 54. Findings Include: Review of the medical record for Resident #23 revealed an admitted on 06/17/22. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #23 required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Resident #23 received daily insulin injections. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The order had a start date on 06/18/22 at 7:00 P.M. Resident #23 also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #23 received a one time dose on 06/18/22 of Insulin [MEDICATION(S)] Solution. However, Resident #23 did not receive [MEDICATION(S)] until 06/20/22. Resident #23 was not administered any insulin on 06/19/22 as ordered. Review of the Admission Assessment & Baseline Care Plan dated 06/17/22 revealed diabetes was not marked as a part of Resident #23's medical history. Vital signs did not include a blood sugar reading and the vital signs documented were dated 01/05/22 and 01/07/22 (five months prior to admission). An admitting weight was not completed. The weight included on the assessment was dated 12/22/21 (six months prior to admission). Review of blood sugar readings dated from admission on 06/17/22 revealed Resident #23 did not receive a blood sugar check until 06/20/22 at 8:48 P.M. The reading was 201 mg/dL. Review of the progress notes dated from 06/17/22 to current revealed there was no admission note for Resident #23. There were not any progress notes related to the missed dose of [MEDICATION(S)]. Review of the plan of care dated 06/18/22 revealed Resident #23 was at risk for [CONDITION(S)] and [CONDITION(S)] episodes related to insulin dependent diabetes mellitus. Interventions included insulin as ordered and monitor blood sugar levels as ordered and as needed for symptoms of [CONDITION(S)] or [CONDITION(S)]. Review of the list of medications stored in the facility's EDK box revealed [MEDICATION(S)] was a medication listed as being stored in the facility's EDK box. Interview on 08/29/22 at 1:55 P.M. with Resident #23 revealed he did not receive medications, including insulin, for approximately two days after being admitted to the facility in June 2022. Interview on 08/31/22 at 5:56 P.M. with the Director of Nursing (DON) and the Administrator confirmed Resident #23 did not receive [MEDICATION(S)] injection on 06/19/22 as ordered. A facility policy related to following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on medical record reviews and staff interviews, the facility failed to provide timely physician ordered laboratory services for two of six residents (Resident #29 and Resident #37) reviewed for medications. The facility census is 54. Findings include: 1. Review of Resident #29's medical record identified admission to the facility occurred on 12/29/21, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #29 was observed to be verbal and able to make her needs known. Resident #29 was noted with a urinary catheter on 08/10/22. Review of Resident #29's progress notes identified on 08/10/22 at 8:57 P.M. confusion was noted and increased behaviors with staff. The staff called the physician whom ordered a UA C&S (urinalysis/culture/sensitivity). The notes identified on 08/11/22 the staff collected the urine sample which was ready for the laboratory to pick up. The progress notes dated 08/12/22 at 8:14 A.M. identified the specimen was collected incomplete and will attempt to collect again. The progress notes identified on 08/13/22 Resident #29 increased confusion persists and the facility is awaiting the urinalysis results. The progress notes identified Resident #29 went to a urology appointment on 08/17/22, with a new order to remove the urinary catheter. The notes identified on 08/18/22 Resident #29 identified I want this marble out. The notes confirmed the urinary catheter was removed on 08/18/22. Review of the record identified no evidence what occurred with the urine sample and or results from the 08/12/22 urinalysis. Interview with the facility Director of Nursing (DON) on 08/30/22 at 2:21 P.M. confirmed there was an order on 08/10/22 for a urinalysis for Resident #29. The interview revealed the laboratory called the facility on 08/17/22 and informed them the urine sample, from 08/12/22 was contaminated and was not able to be processed. The interview identified on 08/18/22 another sampled was collected from Resident #29 and was submitted to the laboratory. The interview identified the laboratory then called and identified that sample had spilled. The interview confirmed the facility did not recollect the sample until 08/22/22. The interview confirmed the results were returned to the facility on [DATE] at which time Resident #29 was diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The interview confirmed the original order for the urinalysis test was on 08/10/22 and this was not completed and returned for Resident #29, treatment until 08/26/22 (16 days later). 2. Resident #37 was admitted to the facility 09/11/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual minimum data set (MDS) 3.0 assessment dated [DATE] confirmed the resident was cognitively intact, had no delusions, or hallucinations but did have daily rejection of care. The resident required assist for bed mobility, dressing, toileting, hygiene. and was dependent on staff for transfers. Review of resident medication orders revealed the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the pharmacy recommendation written on 08/18/22 revealed the recommendation requested the provider to consider a [MEDICATION(S)] level to ensure non-toxic levels of the medication, as the resident had received [MEDICATION(S)] 50 mg three times daily. The physician reviewed the recommendation and ordered a [MEDICATION(S)] level with the next laboratory day dated 08/22/22. Review of the laboratory rejected report provided by the facility revealed the resident had a [MEDICATION(S)] level obtained on 08/23/22. The report revealed the specimen was rejected as the specimen was not placed in the correct collection tube. Review of the laboratory requisition form dated 08/25/22 revealed Resident #37 had a [MEDICATION(S)] level re-drawn. During an interview with the Director of Nursing (DON) on 09/01/22 at 10:41 A.M. it was confirmed on 08/23/22 the resident had a [MEDICATION(S)] laboratory test collected, however the test was initially placed in the wrong tube for laboratory processing by the laboratory employee who drew the resident's blood. The laboratory test was recollected on 08/25/22 and the facility was told the laboratory test had to be sent to a reference laboratory for processing. The DON revealed on 08/30/22 at 4:14 P.M. the facility was informed by the laboratory the [MEDICATION(S)] level was pending and could take up to 15 days to complete. The DON revealed the laboratory called the facility back on 08/30/22 at 5:08 P.M. and stated the laboratory cannot use the sample they had collected for Resident #37 on 08/25/22 there was no explanation provided for why the laboratory specimen was unusable. The laboratory stated to the facility they were sending another phlebotomist to draw another specimen and test would be completed stat. The facility stated they were in contact with the laboratory on 09/01/22 and the [MEDICATION(S)] level is still pending. The DON indicated the laboratory could not tell the facility the time frame it would take to complete the [MEDICATION(S)] serum level to be completed.

Based on observations, staff interviews, policy review, review of the Department of Health and Human Services Centers for Medicare & Medicaid Services (CMS) Memo QSO-20-14-NH (revised 03/10/21), review of the World Health Organization (WHO) hand hygiene brochure and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility staff failed to ensure hand hygiene was consistently implemented to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). This affected three (#43, #44 and #39) random residents observed during meals. Facility census was 56. Findings include: Observations during the breakfast meal service on 09/22/21 at 8:30 A.M. on the 100 hall revealed State tested Nursing Assistant (STNA) #61 went room to room serving meal trays to Resident #43, #44 and #39. The observations revealed STNA #61 did not perform hand hygiene. STNA #61 touched and repositioned tray tables, beds and residents in each of the resident rooms. Interview with STNA #61 on 09/22/21 at 8:37 A.M. after Resident #39 was served verified she did not complete hand hygiene after serving each resident. Interview with the Director of Nursing (DON) on 09/22/21 at 8:45 A.M. revealed the facility was in outbreak status since a resident tested positive for COVID-19 on 08/26/21 until there were no new positive cases for 14 days. The DON stated staff received training regarding hand hygiene starting 08/27/21. Review of the policy titled Hand Hygiene dated 11/28/17 revealed hand hygiene was properly performed to assist in the prevention of spreading infections. Staff performed hand hygiene using proper technique which included before and after contact with a resident and surfaces in a resident's environment. Review of CMS policy memo QSO-20-14-NH revised 03/10/21 titled, Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes, revealed facilities were to Increase the availability and accessibility of alcohol-based hand rubs, and to reinforce strong hand-hygiene practices. Review of the CDC training titled, Hand Hygiene in Nursing Homes, dated 02/25/19, revealed hand hygiene is an element of standard precautions. It is an important Infection Prevention Control (IPC) practice for breaking the chain of infection. Hand hygiene protects both residents and staff. Hand hygiene is a simple and effective method for preventing the spread of pathogens by direct and indirect contact. The hands of staff members may become transiently contaminated with pathogens after touching a resident or surfaces in their environment. Staff members can transfer those pathogens to themselves and they can also transfer those pathogens to other residents or surfaces. Performing hand hygiene removes pathogens and protects both staff and residents. Since staff cannot tell whether their hands have been contaminated with a pathogen, hand hygiene should be consistently performed. Review of the World Health Organization (WHO) Hand Hygiene brochure titled Hand Hygiene: Why, How, and When?, revised August 2009, revealed hands are the main pathways of germ transmission during health care and hand hygiene is therefore the most important measure to avoid the transmission of harmful germs and prevent health care-associated infections. The brochure further revealed hand hygiene is indicated after touching any object or furniture when leaving the patient surroundings to protect the health-care environment against germ spread. This deficiency substantiates Complaint Number OH 812.

Based on record review and interview the facility failed to administer medication as ordered for Resident #23. This affected one (Resident #23) out of three residents reviewed for medication administration. Findings include: Review of medical record revealed Resident #23 was admitted on [DATE] with diagnosis that included [CONDITION(S)] syndrome, hypertension, and [CONDITION(S)]. Review of physician order dated 10/23/20 revealed Resident #23 was ordered [MEDICATION(S)] (diuretic) 40 milligram (mg) by mouth in the morning. Review of the medication administration record (MAR) from 01/01/21 through 02/03/21 revealed Resident #23 was not administered nine doses of [MEDICATION(S)] 40 mg. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #23 was cognitively intact. Review of physician order dated 02/03/21 revealed Resident #23 was ordered [MEDICATION(S)] 40 mg by mouth twice a day. Review of the MAR from 02/04/21 to 03/31/21 revealed Resident #23 was not administered 20 doses of [MEDICATION(S)] 40 mg in the morning. Interview on 04/05/21 at 3:40 P.M. Registered Nurse (RN) #450 revealed Resident #23 did not want to take [MEDICATION(S)] on the days he had [CONDITION(S)]. The resident stated he would take [MEDICATION(S)] on the next shift. RN #450 verified she had not administered the morning [MEDICATION(S)], had not marked the MAR that the resident refused, had not notified the physician of the resident refusing, and had not checked about getting the times changed for the administration of [MEDICATION(S)].

Based on medication administration observations, review record, review of the facility policy, review of the inhalation medication manufacturers instructions and staff interviews, the facility failed to follow the manufacturers instructions/facility policy for the use of inhalation medications to maximize the effectiveness of the medication. This affected one (#22) of three residents observed during medication administration. The total facility census was 59. Findings include: Review of Resident #22's medical record, including current physician orders, revealed all three inhalation medications were ordered including [MEDICATION NAME], [MEDICATION NAME] Diskus and Breo Ellipta. However, there were no instructions for the order of how they should be administered and/or if there should be wait times between the inhalers. Observation of the medication administration on 02/23/21 at 7:54 A.M. with Registered Nurse (RN) #200, revealed RN #200 gathered a total of 11 pills, including Folic Acid 400 micrograms (mcg) and three different inhalers including [MEDICATION NAME], [MEDICATION NAME] Diskus and Breo Ellipta for Resident #22. The observation identified Resident #22 took all 11 pills and was handed the [MEDICATION NAME] Diskus inhaler, immediately followed by the Breo Ellipta inhaler and then [MEDICATION NAME] inhaler. Resident #22 completed the first two inhalers back to back without any wait time and was unable to push the [MEDICATION NAME] inhaler, therefore, the nurse provided two puffs, again without any wait time. Interview with RN #200 on 02/23/21 at 9:02 A.M., verified she did not wait any length of time between the three different inhalers, did not remind the resident to rinse her mouth out following the [MEDICATION NAME] or Ellipta and did not realize they should be administered in a particular order. Review of the facility's policy regarding pharmacy for inhalation medications dated 04/12/12, revealed if more than one puff was required, whether the same medication or different, the manufacturers product information for administration instructions including wait time between inhalations should be followed. Review of the manufactures instructions for the [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) identified to wait one minute between the same medications. The instructions identified the [MEDICATION NAME][MEDICATION NAME] should be used first and wait five minutes, to allow the airway to open before administration of corticosteriods. Review of the manufacturers instructions for [MEDICATION NAME] (steroid) identified to rinse the mouth with water and spit after each dose to lessen getting thrush (infection) in the mouth. Review of the manufacturers instructions for Ellipta identified to rinse the mouth with water and spit after each dose to lessen getting thrush (infection) in the mouth. This deficiency substantiates Master Complaint Number OH 577.

Based on medication administration observations, record review, review of the facility policy, review of the inhalation medications manufacturers instructions and staff interviews, the facility failed to ensure a medication error rate of less than 5%. The facility had a total of three medication errors with 26 opportunities for an error rate of 11.5%. This affected one (#22) of three residents observed during medication administration. The total facility census was 59. Findings include: Review of Resident #22's medical record, including current physician orders, revealed an order for [REDACTED]. Further review of the physician orders revealed all three inhalation medications were ordered including [MEDICATION NAME], [MEDICATION NAME] Diskus and Breo Ellipta. However, there were no instructions for the order of how they should be administered and/or if there should be wait times between the inhalers. Observation of the medication administration on 02/23/21 at 7:54 A.M. with Registered Nurse (RN) #200, revealed RN #200 gathered a total of 11 pills, including Folic Acid 400 mcg and three different inhalers including [MEDICATION NAME], [MEDICATION NAME] Diskus and Breo Ellipta for Resident #22. The observation identified Resident #22 took all 11 pills and was handed the [MEDICATION NAME] Diskus inhaler, immediately followed by the Breo Ellipta inhaler and then [MEDICATION NAME] inhaler. Resident #22 completed the first two inhalers back to back without any wait time and was unable to push the [MEDICATION NAME] inhaler, therefore, the nurse provided two puffs, again without any wait time. Interview with RN #200 on 02/23/21 at 9:02 A.M., verified she did not wait any length of time between the three different inhalers, did not remind the resident to rinse her mouth out following the [MEDICATION NAME] or Ellipta, administered Folic Acid 400 mcg instead of the ordered 600 mcg and did not realize the [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) should be given before the steroid inhalers with a five minute wait time to allow the medication to open the airways. Review of the facility's policy regarding pharmacy for inhalation medications dated 04/12/12, revealed if more than one puff was required, whether the same medication or different, the manufacturers product information for administration instructions including wait time between inhalations should be followed. Review of the manufactures instructions for the [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) identified to wait one minute between the same medications. The instructions identified the [MEDICATION NAME][MEDICATION NAME] should be used first and wait five minutes, to allow the airway to open before administration of corticosteriods. Review of the manufacturers instructions for [MEDICATION NAME] (steroid) identified to rinse the mouth with water and spit after each dose to lessen getting thrush (infection) in the mouth. Review of the manufacturers instructions for Ellipta identified to rinse the mouth with water and spit after each dose to lessen getting thrush (infection) in the mouth. Interview with the Director of Nursing (DON) on 02/23/21 at 3:24 P.M., verified the facility called the physician regarding the medication errors for Resident #22 and obtained a new order for the Folic Acid and inhaler timing. This deficiency substantiated Master Complaint OH 7.

Based on observations, review of medical records, review of the facility summary of event, review of menus and recipes for the mechanical soft diet texture, interviews with residents, family, and staff, review of employee disciplinary action, and review of in-service records/audits, the facility failed to ensure residents on mechanically altered diets were provided food in the correct texture assessed to meet their individual needs. This resulted in Immediate Jeopardy for one (#114) resident who experienced serious potential life-threatening harm when they were served the incorrect texture of food items at their meal and subsequently choked requiring staff intervention to perform the [MEDICATION NAME] maneuver in an effort to remove the food bolus from the trachea where it was preventing air flow to and from the lungs. This affected one (#114) of three residents reviewed for choking. The facility identified ten residents who were on mechanically altered diets. The facility census was 67. On [DATE] at 5:30 P.M., the Administrator was notified Immediate Jeopardy began on [DATE] at 5:40 P.M. when Resident #114 was served a regular roast beef deli sandwich cut into small bites, instead of a ground meat deli sandwich, contrary to the resident's physician order for [REDACTED].#325 notified the nurse who initiated the [MEDICATION NAME] maneuver in an attempt to clear the resident's airway. A piece of meat approximately two inches by one half inch was expelled during the procedure; however, Resident #114 subsequently expired at the facility on [DATE] at 6:07 P.M. The Immediate Jeopardy was removed on [DATE] at 1:30 P.M. when the facility implemented the following corrective actions: · On [DATE], Registered Dietitian (RD) #401 provided in-service education to dietary staff regarding menus and spreadsheets, meal preparation and accuracy, and menu/recipe identification for mechanically altered diet textures including what specific foods were allowed and a description of each modified texture for each type of food item. The Administrator, Director of Nursing (DON) or designee began educating all nursing staff regarding the diet identification by the meal ticket to validate the food consistency at the point of service to the resident. Any staff including any new hires that did not receive the in-service will be educated prior to their next scheduled shift. Two staff were re-educated on [DATE], after lacking appropriate responses regarding identifying mechanically altered diets and the training they had received. These two staff members were re-interviewed after being re-educated and their responses were appropriate and they were knowledgeable regarding mechanically altered diets. · On [DATE], RD #401 and the Administrator completed audits of all resident physician orders compared with the corresponding dietary meal tickets. RD #401 also verified appropriate food production of all mechanically altered diets. · On [DATE], RD #401 audited all resident diets and physician orders to ensure all residents were receiving the proper diet. There were discrepancies for three resident's physician orders that required corrections and were completed by the DON or designee by [DATE]. RD #401 also audited resident meal tickets to ensure they matched the current order. Three days of audits, completed prior to the [DATE] annual survey, were 100 percent accurate. · On [DATE], a Quality Assurance Performance Improvement (QAPI) committee meeting was held with the Medical Director to review the case, action plan and audits. Meal ticket updates or recommendations were completed by RD #401 or the Dietary Coordinator. · On [DATE], Cook #359 received a written warning for failure to follow the menu spreadsheet/recipe for mechanical soft deli sandwiches on [DATE]. · On [DATE] from 8:30 [NAME]M. to 6:20 P.M., interviews with 23 (#112, #12, #50, #24, #55, #35, #20, #43, #45, #61, #214, #217, #39, #15, #220, #26, #27, #49, #59, #52, #18, #164, and #37) residents and three (#13, #215 and #18) family members, revealed no concerns regarding diet textures and indicated they received the proper diet. In addition, a resident group meeting on [DATE] at 10:00 [NAME]M. with five (#30, #50, #31, #6 and #53) residents, revealed they received the correct diet order. · On [DATE] at 12:00 P.M., meal observations of the two dining areas and room trays, revealed management personnel were in place and meal tickets were being verified before residents were served their meals. Continued meal observations on [DATE] at all meals noted all the residents were served the correct physician ordered diets, including the mechanically altered diets with no concerns observed. · On [DATE] at 11:00 [NAME]M., observations were made of dietary staff preparing mechanically altered and pureed foods correctly with no concerns noted. · On [DATE], the medical records for Residents #24 and #13 were reviewed for choking, dysphagia, swallowing difficulties, and mechanically altered diet textures with no identified concerns noted. · On [DATE] between 9:00 [NAME]M. and 1:30 P.M., interviews with Dietary Cooks #360 and #359, STNAs #415 and #416, Registered Nurse (RN) #305, and Licensed Practical Nurse (LPN) #314, revealed all staff were able to describe appropriate mechanically altered diets and the plan that had been implemented. STNA #419 and Dietary Staff #417 initially did not remember the recent training when interviewed and were re-educated by the Administrator on [DATE] by 1:30 P.M. After this additional training, all staff were able to verify they had been in-serviced regarding resident diets and food consistencies with appropriate understanding. Although the Immediate Jeopardy was removed, the facility remained out of compliance at severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy), as the facility is in the process of implementing their corrective actions and monitoring for effectiveness and on-going compliance. Findings include: Medical record review for Resident #114 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Further review indicated the resident's son was the Power of Attorney (POA). Review of the physician ordered diet dated [DATE] revealed the resident had a Low Concentrated Sweets (LCS), mechanical soft solids with finger foods as available, and nectar thick liquids with no straws. In addition, the resident received nutrition via a nocturnal enteral tube feeding. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had both short and long-term memory impairment, had severely impaired decision making skills and her speech was unclear. She required extensive assistance of one staff for feeding and received more than 51 percent of her nutrition via a nocturnal tube feeding. Review of the resident's dementia care plan, initiated [DATE] and revised [DATE], revealed the resident had poor safety awareness and a cognitive communication deficit. Review of the dental care plan initiated [DATE] and revised [DATE], revealed the resident did not wear her full upper dentures and had lower missing teeth. Review of the nutritional status care plan initiated [DATE] and revised [DATE], revealed the resident was at risk for altered nutrition due to dysphagia and was dependent on both the staff and an enteral feeding for nutrition support. Review of the notes from Speech Language Pathologist (SLP) #405 revealed she worked with the resident from [DATE] to [DATE] with the goal of progressing from a pureed diet to a mechanical soft diet. The reason the resident was referred to therapy on [DATE], was due to swallowing improvements reported by nursing during meals. The Speech Therapy Plan of Care dated [DATE], indicated the resident had dysphagia caused by a stroke and was edentulous. On [DATE], the SLP's discharge summary revealed the resident could safely consume nectar liquids with mechanical soft consistency utilizing a spoon and finger foods. Recommended swallowing strategies included for the staff to supervise the resident with taking small bites, eating slowly, placing food on the left and checking the right side of the mouth for pocketing, and clearing the mouth prior to taking the next bite. Review of the nursing progress note revealed on [DATE] at 5:45 P.M., LPN #400 was on the 100 hall and heard STNA #325 yelling for help in the dining room. Resident #114's color was changing and LPN #400 immediately completed the [MEDICATION NAME] Maneuver which expelled some food. STNA #325 went to get another nurse and at this time the resident was breathing. Resident #114's blood pressure was ,[DATE], pulse 73, and oxygen saturation was 85 percent. Two liters of oxygen was provided via nasal canula and emergency services were notified and arrived at 6:04 P.M. The Do Not Resuscitate Comfort Care-Arrest (DNRCC-A) code status was confirmed. The emergency staff provided mechanical respiration with an Ambu bag until 6:07 P.M., when the resident was asystole and the time of death was called. The resident's son, who was her power of attorney, was notified at 6:30 P.M., as well as the physician. The note documented the resident received a mechanical diet per physician order and was under the direct supervision of an STN[NAME] Review of the, Certificate of Death for Resident #114, revealed she expired on [DATE] due to dysphagia from the late effects of a stroke. Review of the discharge note dated [DATE], completed by the physician/Medical Doctor (MD) #406, revealed the resident developed asystole/[MEDICAL CONDITION] on [DATE]. DNRCC-A resuscitation attempts were not provided by emergency medical staff and the resident expired. Review of the document titled, Quality Assurance Performance Improvement (QAPI) Summary of Event, revealed Resident #114 was sitting upright in her wheelchair in the dining room on [DATE]. STNA #325 provided the resident thickened liquids, cut her food into small pieces and started feeding her. At approximately 5:40 P.M., the resident choked. STNA #325 called for LPN #400 who came to the dining room, performed the [MEDICATION NAME] maneuver and expelled a small piece of food from the resident. Nursing staff supervised the resident during the event. Her oxygen saturation levels went from 85 percent to 79 percent and oxygen was administered. STNA #325 called for additional assistance from the other hall nurse. Emergency services were notified, arrived at 6:04 P.M. and bagged the resident who went into asystole. The STNA transported the resident to her room, placed her in bed and performed post mortem care. Review of an undated statement completed by STNA #325, revealed on [DATE] at 5:40 P.M., the resident started to choke on a piece of meat, and she called for the nurse who provided the [MEDICATION NAME] around 5:45 P.M. Review of the menu for the evening meal on [DATE], revealed the mechanical soft diets should have received a ground deli sandwich. The recipe for ground deli sandwiches indicated to pulse/grind the lunch meat until the mixture was the texture of finely ground beef, then add mayonnaise and mustard. These menus and recipes were approved by an RD. Interview on [DATE] at 8:35 [NAME]M. with Dietary Coordinator (DC) #378, revealed Resident #114 had a mechanical soft diet order, was served a deli roast beef sandwich, choked and expired. She stated Cook #359 made an error by serving regular deli roast beef sandwiches to the mechanical soft diets. Interview with RD #401 on [DATE] at 2:40 P.M., revealed Cook #359 should have followed the menu spreadsheet/recipe but instead made an error and served four slices of deli meat to the ten (18, #48, #56, #24, #31, #05, #26, #13, #28 and #114) residents who received mechanical/soft diets at supper on [DATE]. Interview with Cook #359 on [DATE] at 2:45 P.M., revealed she has been a cook for almost two years and always served four slices of deli meat for the mechanical/soft sandwich because she was not trained properly. She verified the menu spreadsheet indicated, ground deli meat for the mechanical/soft diets. She verified she received a written warning on [DATE] for failing to follow the menu spreadsheets/recipe for mechanical soft diets. Interview with LPN #400 on [DATE] at 2:55 P.M., revealed she was in a room assisting another resident and heard staff yelling for help. STNA #325 stayed with the resident who was choking and whose lips were turning blue. LPN #400 stated she applied the [MEDICATION NAME] maneuver and a piece of roast beef approximately two inches long by a half inch wide was expelled from the resident's mouth. There was no other visible food in the residents' mouth. Oxygen saturation levels were 85 percent initially when two liters of oxygen were applied, then dropped to 79 percent saturation. At that point, LPN #400 called for another nurse to assist and she went to call emergency services who arrived within a few minutes and used an Ambu bag to provide the resident with manual respirations until the resident expired. Interview [DATE] at 9:15 [NAME]M. with SLP #405, revealed the resident had a stroke with right sided weakness and used a spoon/fingers to feed herself a mechanical soft diet with nectar thick liquids when she was discharged from therapy on [DATE]. The resident had no teeth and usually did not wear her dentures. She received staff supervision and spoon feeding as needed during the meals in the dining room. SLP #405 stated she trained the staff regarding the swallowing strategies for the resident; however, verified there was no documentation of the training. Phone interview with Medical Director #406 on [DATE] at 1:52 P.M., revealed he was told the resident's cause of death was a choking episode on [DATE]. MD #406 stated the nurse managed to dislodge the food, the resident's vitals returned to baseline, she went into asystole/[MEDICAL CONDITION], the squad was called and they were not able to save the resident. The physician understood she was on a mechanical soft diet and the food served to her was appropriate. He was not aware the resident received a regular roast beef sandwich. Phone interview on [DATE] at 2:20 P.M., with Resident #114's son who was the POA, revealed he was not aware the resident received a regular roast beef sandwich cut into pieces for supper the evening she expired. He stated his mother would not be able to handle a roast beef sandwich but could eat sandwiches like chicken salad or egg salad because she never wore her dentures. Interview with STNA #410 on [DATE] at 9:20 [NAME]M., revealed the resident was mostly fed by staff, used her fingers to put food in her mouth and rarely fed herself with utensils. The resident would pocket food and staff needed to monitor to make sure she was swallowing between bites. Phone interview with LPN #400 on [DATE] at 2:14 P.M. verified she did not inform the resident's physician (MD #406) or Resident #114's son, the resident received a regular roast beef sandwich instead of mechanical soft meat when she notified them of Resident #114's death. LPN #400 stated she did not realize the resident received a regular roast beef sandwich and had not received the mechanical soft meat, as ordered by the physician prior to the residents death. Interview with STNA #325 on [DATE] at 2:30 P.M., revealed she had never seen the resident receive a regular roast beef sandwich prior to supper on [DATE] around 5:30 P.M. When she questioned Cook #359 about serving the roast beef sandwich on a mechanical/soft diet, the cook stated the roast beef sandwich was appropriate. STNA #325 stated she cut the sandwich into small half inch bite size pieces and started feeding the resident with a fork. The resident was also placing some of the sandwich bites in her mouth with her fingers. STNA #325 stated she was trained by SLP #405, to check the resident's mouth between bites to make sure she was swallowing and to provide nectar beverages every few bites. After the resident was eating for about 10 minutes, the STNA noticed the resident was choking and called for the nurse who completed the [MEDICATION NAME] maneuver and the resident spit out a little piece of meat. This deficiency substantiates Complaint Number OH 782.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure a State tested Nursing Assistant (STNA) #412 wore appropriate personal protective equipment (PPE) and performed hand hygiene during personal care for a resident in isolation. This affected one Resident (#164) of one reviewed for isolation. This had the potential to affect eight Residents (#5, #26, #27, #29, #53, #58, #59 and #162) who resided on the hall where STNA #412 was assigned. The facility census was 67. Findings include: Review of the medical record for Resident #164 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the nursing admission assessment dated [DATE], revealed Resident #164 had no cognitive deficits. He was also noted to be on intravenous (V) antibiotics for ESBL in his urine. Resident #164 was listed being in isolation for contact precautions. Observation on 10/30/19 at 8:47 [NAME]M. revealed STNA #412 was assisting Resident #164 out of his bathroom to his chair. STNA #412 did not have PPE on, nor was she wearing gloves during her care for Resident #164. At 8:48 [NAME]M. STNA #412 exited Resident #164's room and did not wash her hands. At 8:50 [NAME]M. STNA #412 confirmed she had not worn and PPE while caring for Resident #164, nor did she wash her hands before exiting the resident's room. STNA #412 also confirmed she did know the policy for contact isolation and stated staff should wear gown and gloves when entering an isolation room. Review of the facility's policy titled Transmission-Based Precautions: Contact Precautions, dated 07/2014, revealed gloves should be worn when entering an isolation room. Hand hygiene should be performed immediately with an Antimicrobial agent before leaving the room. In addition, a gown should be worn when entering the room if the staff anticipated their clothes may encounter the resident or environmental surfaces or items in the resident's room.

Based on observations and resident and staff interviews, the facility failed to provide a bed that accommodated the height for one (#43) of 19 residents and failed to accommodate fried egg preferences for four (#43,#37, #35 and #20) of 19 residents reviewed for accommodation of needs. The total facility census was 67. Findings include: 1. Review of Resident #43's medical record revealed the resident was admitted to the facility on [DATE], transferred to a local hospital on [DATE], and returned to the facility on [DATE], in a room closer to the nurse's station as a fall precaution. [DIAGNOSES REDACTED]. Resident #43's Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #43 was cognitively intact and required extensive assistance from staff for activities of daily living. Interview and observation on 10/29/19 at 11:18 [NAME]M. with Resident #43, revealed his mid calves and feet were hanging off the bed. Resident #43 stated he had talked to staff a few days after he had returned to the facility from the hospital about getting an extender for his bed, but no one had followed up. Resident #43 stated he was six foot, three and a half inches. During an interview on 10/29/19 at 11:22 [NAME]M., Interim Social Service Designee (ISSD) #1 revealed prior to Resident #43's hospital transfer, he had been in a different room with a longer bed. She stated she was not sure why Resident #43 did not have the same sized bed as when he was here prior. ISSD #1 stated the facility would provide him the bed extender by the end of 10/29/19. 2. Observations during the kitchen tour on 10/28/19 starting at 8:20 [NAME]M., revealed the facility had no shell pasteurized eggs available if any resident requested a fried egg. Interview on 10/28/19 at 8:25 [NAME]M. with Dietary Coordinator (DC) #379, verified there were no shell pasteurized eggs available at any time for any resident if they requested a fried egg. DC #379 stated the residents were told they had to stick to the available menu egg alternatives such as an omelet or hard boiled egg. Interview on 10/28/19 at 8:55 [NAME]M. with Cook #358, revealed if a resident requested a fried egg we apologized and explained that fried eggs were not available and offered an omelet or hard boiled egg instead. Interview with Resident #43 on 10/28/19 at 9:42 [NAME]M., revealed she preferred fried eggs over the omelet or scrambled eggs but indicated the staff would not serve fried eggs as an option. Interview with Resident #37 on 10/28/19 at 12:00 P.M., revealed the staff do not offer fried eggs as an option. The resident preferred fried eggs which were not offered. Interview with Resident #35 on 10/28/19 at 12:49 P.M., revealed she would like a fried egg over easy at times but it was not a choice. Interview with Resident #20 on 10/28/19 at 01:08 P.M., revealed she would love a fried egg over easy sandwich but the staff stated no, that was not a choice.

Based on record review, staff interview, and review of facility policy, the facility failed to complete a pre-admission screening resident review (PASRR) for one resident who had a [DIAGNOSES REDACTED]. This affected one (#45) of four residents reviewed for PAS/RR's. The facility identified three residents as having [DIAGNOSES REDACTED]. Findings include: Review of Resident #45's record revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #45's 7000 Form (a hospital exemption form allowing the resident to admit to the facility for 30 days before a full PASRR was required), was dated [DATE], and expired [DATE]. After surveyor intervention, the facility provided a PASRR dated [DATE], with the appropriate [DIAGNOSES REDACTED].#45 did not require level two PASRR services. Interview on [DATE] with Corporate Registered Nurse #411, confirmed Resident #45's PASRR had not been completed within 30 days from the hospital exemption. She confirmed the PASRR was completed by the facility on [DATE], 11 days after the exemption expired and Resident #45's [DIAGNOSES REDACTED]. Review of a facility policy titled, Pre-admission Screening and Resident Review (PASRR)-Ohio, revised (MONTH) (YEAR), revealed the facility would ensure the PAS/RR process was maintained for all residents to ensure individuals were evaluated for a serious mental disorder and/or intellectual disability and that those identified individuals were offered the most appropriate setting. The policy further revealed prior to resident admission, the admission coordinator would ensure either the hospital exemption form or PASRR was completed. The policy revealed the facility would complete the PASRR if a resident admitted with a hospital exemption form and had not been discharged by day 29 of the stay. The PASRR would be completed by day 29 of the resident's stay.

Based on record review, observations, resident, family, and staff interview and policy review, the facility failed to provide the necessary care and services to provide adequate pain management for residents that resulted in harm when Resident #1 experienced uncontrolled pain all night with no relief until the next morning when her spouse brought her something from home for pain. Furthermore, the facility failed to transcribe Resident #3's pain medication as ordered onto the current physicians order in a timely manner. This affected two #1 and #3) out of three reviewed for timeliness of medications. The facility census was 59. Findings include: 1. Medical record review of Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. She was discharged back to the hospital on [DATE] due to right hip dislocated and readmitted to the facility on [DATE]. Review of physicians orders dated 10/23/17 revealed resident had an order for [REDACTED]. Review of hospital continuity of care revealed medication list was faxed to the facility on [DATE] at 11:18 A.M. Review of hospital paper work dated 10/23/17 revealed resident has had multiple revisions due to dislocations and infection and had an antibiotic spacer placed on 10/17/17. X-ray revealed right hip location that was unsuccessfully reduced in the emergency department. The resident had [MEDICATION NAME] at 6:10 P.M. prior to discharge from hospital. Review of admission assessment dated [DATE] revealed Resident #1 was alert and oriented to name, place, and time. Review of nurses note dated 10/24/17 at 12:41 A.M. revealed Resident #1 had returned from the hospital on [DATE] at 8:50 P.M., assessment was completed, medications verification called into physician and medication list not read to doctor per provider and instructed the nurse to make sure resident had all her medications and per hospital report all medications was administered prior to discharge from the hospital. Review of admission documentation dated 10/24/17 at 1:43 A.M. revealed resident verbally expressed pain. There was no numerical pain scale documented and no interventions documented for residents pain. There was no documentation that any pain medications was administered the evening of 10/23/17 or through the night on 10/24/17. Review of Resident #1's nurses notes dated 10/24/17 at 6:50 A.M. revealed day shift nurse spoke with certified nurse practioner and medications verified and okay to administer opioids. Pharmacy was made aware of orders needing to be delivered. Review of nurses notes dated 10/24/17 at 11:47 A.M. revealed that resident complained of pain to right hip at a scale of eight out of 10 at 7:00 A.M. [MEDICATION NAME] 10 mg and [MEDICATION NAME] four mg verified with current medication orders in matrix and husband provided Resident #1 with the medications. Observation on 10/24/17 at 7:00 A.M. revealed Resident #1's spouse yelling at staff. The Administrator was in Resident #1's room talking to the resident and the spouse. Resident #1's spouse was overheard yelling because the resident had not had any pain medicine since admission and the resident was in pain. Interview was conducted on 10/24/17 at 8:35 A.M. with Resident #1 and the spouse. Resident #1 was resting in bed. The spouse stated the resident has had 18 different surgeries on her right hip and now has an apparatus in place to right hip due to infection. Resident #1 stated she returned to facility from hospital around 8:00 P.M. last night and the hospital still was not able to correct her hip dislocation. Resident #1 stated she received pain medication at the hospital around 6:00 P.M. The spouse and resident both stated they were under the understanding from the hospital the facility would have her pain medications available and that they would drop ship her medications. Resident #1 stated she needed pain medication last night and the nurse told her she did not have her pain medications. The spouse stated the nurse suggested to him that he could bring in her pain medicine and that the physician had not approved her medications yet to be ordered. Resident #1 stated she started having muscle spasms in her legs due to pain and that her toes started to curl up and she was in tears all night long. Resident #1 stated she called her spouse on the phone at 6:00 A.M. The spouse stated he brought in medication for her from home and gave it to the resident this morning. Interview was conducted with Resident #1 on 10/24/17 at 2:20 P.M. and she stated she had pain last night when she went to bed and when she asked the night shift nurse for something the nurse told her she could not have anything until morning because they had no script for her medications. She stated her pain last night was at a nine to 10 on a scale from one to 10 with 10 being the worst. Resident #1 stated she had tears a lot through the night and then again asked the nurse at 5:00 A.M. for pain medicine and nurse told her that her spouse could bring in pain medicine for her and that is when she called her spouse. Resident #1 stated she did receive [MEDICATION NAME] and [MEDICATION NAME] from her spouse this morning and that it helped her pain. Interview was conducted on 10/24/17 at 1:55 P.M. with Licensed Practical Nurse (LPN) #65 and she stated she received in report at 7:00 A.M. from the night nurse that Resident #1 was in pain and that her spouse was in and very upset. LPN #65 stated she immediately looked into the concern and called the pharmacy and pulled her [MEDICATION NAME] from the facilities emergency box and when she went to resident's room and her spouse had already administered pain medication to her. LPN #65 stated she was not sure why the night nurse did not give her anything for pain. Interview was conducted on 10/24/17 at 2:53 P.M. with the Director of Nursing (DON) and verified that Resident #1 had not received pain medicine at night because the physician on call on 10/23/17 did not approve her medications. The DON verified the nurse did not try to contact another physician such as the facilities medical director and did not pursue anything further to relive Resident #1's pain and that she just passed it on to the next shift. 2. Medical record review of Resident #3 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of admission assessment dated [DATE] revealed she was alert and oriented and her medications was verified. Review of the hospital continuity of care orders dated 10/19/17 revealed an order for [REDACTED]. Review of October 2017 physicians orders and Medication Administration Record [REDACTED] Observation and interview was conducted on 10/24/17 at 10:41 A.M. with Resident #3 and she was wheeling herself to her room from therapy in wheelchair. She stated no problems with her medications stating she takes Tylenol and was aching and asked the nurse for medicated rub and she received it in a timely manner. She stated the rub was effective in pain relief and that she did not want to take pain medications. Interview was conducted on 10/24/17 at 1:15 P.M. with the DON and she verified that the [MEDICATION NAME] was never entered into the computer or transcribed on the physicians orders and that the medication order was missed for Resident #2. Review of the facilities undated Pain Assessment and Management Protocol revealed the purpose of this procedure is to provide guidelines for assessing resident pain, as well as ongoing monitoring, treatment and evaluation of pain to ensure appropriate pain management. When assessing a resident for pain, the nurse will evaluate resident's verbal expression of a pain score/level as well as non verbal signs and symptoms that could reflect pain. Pain management goals are to promote resident comfort, decrease pain intensity and reduce the risk of the resident from reaching the next highest pain level. At any time, if the resident's pain increases or resident shows signs and symptoms of increased discomfort the physician or nurse practioner will be contacted to evaluate the current pain management plan and any new orders will be followed and implemented for the resident. Episodes of pain are to be documented in the electronic medical record and should include an assessment of the pain including location and severity, the treatment administered, and the effectiveness of the treatment. Review of facilities undated Admission Policy revealed that specific date shall be recorded upon a residents admission to the facility, include time the physicians orders were received and verified and prior to admission the residents attending physician must provide the facility with information needed for immediate care of the resident including medication orders. This deficiency substantiates Complaint Number OH 046.

Based on medical record review, review of an investigation statement, staff interview, family interview, physician interview and personnel file review, the facility failed to ensure Resident #1 received the correct medications resulting in a significant medication error. This resulted in actual harm when Registered Nurse (RN) #11 administered Resident #2's medications to Resident #1, the resident developed a low blood pressure and was subsequently hospitalized . This affected one (#1) of three residents sampled for medication administration. The facility census was 68. Findings include: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE]. Resident #1 was discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's physician orders [REDACTED]. Review of the Minimal Data Set (MDS) revealed it was in the process of being completed and was not fully completed due to the Resident #1's short stay at facility. Review of the Admission Nurse Note dated 02/08/17 revealed the Resident #1 was alert to person, place, time and situation. Review of Registered Nurse (RN) #11 Statement dated 02/12/17 revealed she had prepared oral and subcutaneous medications for Resident #2. Preparation included pills, a liquid antibiotic, and a [MEDICATION NAME] injection. She revealed she confirmed the medications were for Resident #2 and being administered for the correct time, drug, dose, and form for the resident. She then pulled each medication one at a time checking all of the factors, checked again before emptying envelopes and blister packs into the medication cup. On the computer's Medication Administration Record [REDACTED]. She revealed she logged off of matrix and locked the medication cart. She also documented during orientation that B side of the resident rooms, is always to the left as you enter the room. She revealed she looked at the door tags as she entered the room, confirming Resident #2 was on the B side. The resident was in the process of sitting up and she greeted her by name with good morning (Resident #2's first name). She revealed she then set the medications on the bedside table and crouched down to her level before bringing water and the medication cup with the pills in front of her. She revealed the resident looked into the cup and said something along the lines of oh the usual before taking them with the water. She then turned to get the liquid antibiotic and moved the breakfast tray in the process where she saw her meal slip with the name Resident #1 on it. She revealed she immediately did a full stop and asked the resident her name to which she answered Resident #1's name. She revealed she then took the [MEDICATION NAME] injection and the antibiotic out to the medication cart with her and put them away. She revealed she checked the name slips on the door again which were backwards. She revealed she alerted training Licensed Practical Nurse (LPN) #21 and was advised to call the resident's physician and the Director of Nursing (DON). She then went back and took the resident's blood pressure at around 10:15 A.M. and it was 90/60 millimeters of mercury (mmHg). The physician did not answer the phone so she left a message (she was not sure how much time passed between leaving the message and the call back from the physician). When the physician called back she reviewed the medication the resident received, her regular morning medication, allergy information (none related to medications administered), most recent blood pressure (BP) (76/48 mmHg) and her current state (level of consciousness, positioning in Trendelenburg). The physician responded saying that we should hold her diuretics and BP medications (a total of three), monitor vitals for the next four hours, and to add fluids via intravenously (IV) if needed. She revealed she took Resident #1's BP again and then called the DON (at 11:15 A.M.) and alerted him to the situation as well as the instructions from the physician. He asked that we keep him appraised of the situation and to check in as needed. She revealed she returned to Resident #1's room about 20 minutes later after completing the phone calls and told Resident #1 she had received some medications she was not supposed to so we were holding some of her normal medications. She asked if her doctor knew and she responded yes and that she wouldn't be getting some of her normally scheduled medications because of this. She revealed she asked her how she was feeling and she responded fine. She then took her BP again at that point and it was 70/42 mmHg. She told Resident #1 she would be in to check her vitals more frequently over the next few hours. Upon entering the room again she noticed she was slightly harder to arouse but still able to be aroused via voice. She brought the training LPN #21 in and she confirmed that it was a change. She gathered the IV supplies and the saline and called the physician again to confirm placing an IV which another staff member did. She started the saline drip with instructions from the physician that she probably wouldn't see an increase in BP until one to one and a half (1 to 1.5) liters were infused. BP's continued to hover at 70/40 mmHg and she remained in Trendelenburg and continued to be aroused by loud voice and was oriented to self, date, and place. She revealed at handoff (shift change) at 2:30 P.M. or 2:45 P.M. she alerted the incoming nurse to her low BP, including most recent reading, and condition. She conveyed the BP readings too to the teaching nurse and she also took vital signs of her own along with charting progress notes. By the time she left the MAR/ resident room listing was corrected as well as the door tags. Review of the Progress Notes dated 02/11/17 at 4:31 P.M. revealed during shift change the previous nurse (RN #11) stated Resident #1's BP has been low during morning shift. The nurse documented the physician was previously notified and ordered to be called if patient's BP had dropped below 70/40 mmHg. This nurse entered patient's room to assess vital signs. Resident #1's family was at the bedside. At 4:00 P.M. vital signs were BP 42/38 mmHg, pulse 50 beats per minute, respirations 16 per minute, unable to obtain oxygen saturation. Resident #1 was sleeping at this time but was able to be awoken with verbal stimuli. Resident #1 had an IV running with 0.9% Normal Saline, opened the resident's IV line all the way. This nurse called physician whom ordered patient to be sent to emergency room right away. Resident #1 left facility via squad at 4:20 P.M. with family riding along. Review of the local hospital report dated 02/11/17 revealed Resident #1 was recently admitted to the hospital on [DATE] thru 02/08/17 for nausea, vomiting, abdominal pain and [MEDICAL CONDITION]. At the time it was thought she was non- compliant with her [MEDICATION NAME] but improved with [MEDICATION NAME] and Rifaximin. Resident #1 has a history of [MEDICAL CONDITION] virus, [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION], systemic lupus [DIAGNOSES REDACTED]tosus. Resident #1 was given medications that were not hers including [MEDICATION NAME] 6.25 mg; [MEDICATION NAME] 10 mg and [MEDICATION NAME] 20 mg. On speaking to staff from extended care facility, Resident #1 received these medications around 10:49 A.M. She was noted have have low blood pressure of 70/40 mmHg around 2:30 P.M. and then subsequently 42 systolic BP around 4:00 P.M. at which time the squad was called. It was reported that Resident #1 was very lethargic and could not stay away throughout the day but otherwise felt okay. Upon arrival to the emergency room , BP was 55/35 mmHg, pulse 51 beats per minute. Labs showed [MEDICAL CONDITION] to 125 (normal range 135 to 145), elevated creatinine 1.21 from baseline of 0.8, stably elevated Liver Function Test (LFT) and International Normalized Ratio (INR) with MELD-NA (Model of End- Stage Liver Disease) of 31 (27 on last discharge) and pancytopenia slightly worsened from baseline. Chest x-ray showed bilateral [MEDICAL CONDITIONS] appearing stable from recent prior chest x-ray. Resident #1 was given [MEDICATION NAME] one mg for [MEDICAL CONDITION] which increased the heart rate to 60 beats per minute, she was given 2.2 liters of IV fluids and was stated on [MEDICATION NAME]. Given the shock Resident #1 was given one dose of [MEDICATION NAME] and started on [MEDICATION NAME] and [MEDICATION NAME]. Resident #1 was admitting conditions include shock and sinus [MEDICAL CONDITION] secondary to medication toxicity. Further review of Resident #2's medical record revealed RN #11 administered the following medications to Resident #1 on 02/11/17: Magnesium 400 mg; [MEDICATION NAME] 40 mg; [MEDICATION NAME] 60 mg; [MEDICATION NAME] 40 mg; Vitamin B-12 1000 units; [MEDICATION NAME] 6.25 mg; Deltoson 10 mg; Iron 325 mg; [MEDICATION NAME] 120 mg; [MEDICATION NAME] 10 mg; [MEDICATION NAME] 10 mg; Potassium 550 mg and Folic Acid 800 mg. Interview with the Administrator on 02/15/17 at 9:06 A.M. confirmed Resident #1 was administered Resident #2's medication in error by RN #11. He also revealed RN #11 no longer with the facility. The Administrator stated Resident #1's MAR's were wrong in the computerized MAR indicated [REDACTED]. He also revealed education was immediately started on the five rights of medication administration and audits are ongoing. The Administrator also revealed what he felt Resident #1 was originally admitted to the wrong bed as the emergency transport company put Resident #1 in the wrong bed/ side of the room. On 02/15/17 at 10:00 A.M. an attempt to contact RN #11 by phone for an interview revealed there was no answer. Interview with Training LPN #21 on 02/15/17 at 11:30 A.M. confirmed the RN #11's statement of the incident. Training LPN #21 confirmed that he/ she was informed by RN #11 that Resident #1 was accidentally given Resident #2's medications. Interview with Resident #1's family member on 02/15/17 at 2:00 P.M. revealed Resident #1 is in the intensive care unit at a local hospital and is stable. He did say Resident #1 was going to need kidney [MEDICAL TREATMENT] because of this issue. At the current time she is on a ventilator but not due to this issue. Resident #1's family member stated the resident had other health issues. Interview with the Physician #20 on 02/15/17 at 2:30 P.M. revealed Resident #1 did receive Resident #2's medication; however the resident did not get any medications that would have made her react this way. Physician #20 stated Resident #1 was on BP medications anyway. Resident #1 received different BP medications that were ordered for Resident #2 but nothing that would have made her respond the way she did. He also revealed Resident #1 did not respond to the fluids being administered IV and if it was the medications she would have responded. He revealed Resident #1 had been in the hospital previous to her admission and he felt this was a part of it. He also revealed he was looking over the hospital documentation and feels like this was more to do [MEDICAL CONDITION] and infection of the liver. Physician #20 stated this incident was just a coincidence to the underlying problem of her liver issues, he revealed. He also revealed all the medications have been flushed from Resident #1's system and she is still not responding the way she should be. Review of the RN #11's Personnel File revealed she was hired on 02/06/17 as a part time RN. She is no longer employed by the facility. Review of RN #11 orientation checklist revealed the nurse was signed off on oral medication administration. This deficiency substantiates Master Complaint Number OH 686 and Complaint Number OH 593.