Every finding on record at Van Wert Manor

Based on medical record review, staff and physician interviews, review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), and policy review, the facility failed to timely identify the resident's pressure ulcer until it reached an advanced stage, and failed to accurately assess and provide timely interventions to treat the pressure ulcer. This resulted in Actual Harm to Resident #52 who was at risk for pressure ulcers and the facility found Resident #52's pressure ulcer as an unstageable pressure ulcer (Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar) and required surgical debridement of the pressure wound. This affected one (Resident #52) of one resident reviewed for pressure ulcers. The facility census was 53. Findings include: Review of the medical record of Resident #52 revealed an admitted [DATE]. Diagnoses included quadriplegia, anemia, diabetes mellitus, and diabetic neuropathy. Review of Resident #52's care plan dated 01/13/25 revealed Resident #52 was at risk for skin breakdown due to decreased mobility/quadriplegia, weakness, moisture, prediabetes and dry scalp. Interventions included observing skin for redness and open areas and notifying the nurse, skin assessment as needed, and applying lotion/moisture barrier cream as ordered. On 01/23/25, an intervention was added to apply a bariatric bed with alternating pressure air mattress to maintain skin integrity. On 04/16/25, interventions were added to apply negative pressure wound therapy (NPWT) to left buttock wound to ensure dressing is intact and adhering and was started on a scheduled turning plan. There was no mention of any refusal of care behavior. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was cognitively impaired and dependent on staff for all aspects of daily care. Resident #52 did not have any pressure wounds, was at risk for skin breakdown, and had pressure relieving devices for the bed and chair in chair in place. Resident #52 did not have any rejection of care during the review period. From 01/12/25 to 01/27/25, there was no documentation of any skin breakdown and wound measurements in Resident #52's medical record. On 01/22/25, there was a physician order for a low air loss mattress to be applied to Resident #52's bed to prevent any further skin breakdown. On 01/27/25, there was a physician order to monitor dressing to the left buttocks and coccyx to ensure intact and adhering every shift. May change as needed (PRN). The order did not specify any treatment of the wound. The physician orders were given by Physician (MD) #401. Review of the progress note dated 01/28/25, authored by Director of Nursing (DON), revealed an area of skin impairment to the left buttock. The note indicated the wound appeared to be from the adhesive on the foam dressing had peeled the skin away. There was no documentation as to the size or appearance of the wound. The area was cleansed (no specified cleaning agent mentioned) and had no odor or drainage. A dressing (no specification to what type of dressing) had been applied to the wound and Resident #52 denied pain. There was no mention of a coccyx wound. An update was left for Physician Assistant (PA) #402 for morning rounds. The progress note, dated 01/29/25 and written by PA #402, revealed Resident #52 was seen for some green discharge around his catheter as well as some small ulcerations. The note stated Resident #52 was dealing with wound care for what sounds like a coccyx pressure wound (not specified what stage of pressure wound). The plan was to refer to urology. Nothing was said about the left buttock wound. The progress note dated 02/01/25 at 10:00 P.M., written by Licensed Practical Nurse (LPN) #332, revealed a Certified Nursing Assistant (CNA) had reported the dressing to the left buttock had fallen off and was soiled. LPN #332 had not visualized the dressing as it had been thrown away. LPN #332 documented the wound bed was moist and red with a scant amount of sanguineous (bright red blood mixed with yellow fluid) drainage. On 02/05/25, the Skin Issue note was the first documentation of Resident #52's wound measurements and description of the wound. The DON revealed the wound to the left buttock was now an unstageable pressure ulcer/injury (acquired in-house). The wound was assessed as having 100% (percent) slough (a colored non-viable tissue) and measured one centimeter (cm) in length by three-point four cm in width with a moderate amount of serosanguineous (typically pale, yellow, red, and watery fluid). No odor was noted. A note indicated the wound had begun as a skin tear from removing adhesive dressing but had progressed to pressure injury. The dressing had been heavily saturated with drainage. The area was cleaned with soap and water and covered with foam dressing. Resident #52 was sent to the emergency roiagnom on [DATE] and admitted for urinary tract infection and pneumonia. Resident #52 returned to the facility on [DATE]. The Skin Issue note date 02/14/25 revealed the wound to the left buttock was unchanged. There were no measurements or descriptions of the wound. There was no physician order for treatment of the left buttock wound until 02/19/25. The physician order dated 02/19/25 revealed an order to gently clean the left buttock wound with soap and water, rinse and pat dry, apply foam dressing topically as needed and every Monday and Thursday. The Skin Issue note dated 02/26/25, written by the DON, revealed the left gluteus (buttock) measured one cm in length by one cm in width and indicated as stable. The skin around the wound was attached, fragile, and blanchable with a normal temperature. The Skin Issue note dated 03/05/25, written by the DON, revealed the wound to the left gluteus had increased in size and now measured three-point five cm in length by one-point two cm in width. The wound was covered 100% with eschar (a brown or black non-viable tissue) with moderate amount of seropurulent (mixture of purulent and serous) drainage and had an odor after cleaning. The wound bed was a dark colored eschar, the wound felt boggy and had increased in odor with purulent drainage. There was an order for consultation with MD #403. There was no documentation found in Resident #52's medical record indicating MD #403 had been notified. A progress note dated 03/07/25, written by Certified Nurse Practitioner (CNP) #405, revealed he had been contacted to do a wound check on Resident #52. The wound was to the left buttock. Nursing reported having first identified the wound about a month ago. Resident #52 reports having some pain in the wound and has been repositioned in the chair and/or bed to help with the pain. The physical examination revealed a wound to the left buttock approximately three cm in length by one cm in width with mild erythema (reddened tissue) with area of four cm in length and two cm in width. Partial thickness skin loss and yellow sloughing tissue in the wound bed. The assessment stated the wound needs debridement (surgical removal of non-viable tissue). The plan was to perform an incision and drainage of the left buttock wound under local anesthesia in the operating room with MD #403. An Interval History and Physical dated 03/13/25, written by MD #403, revealed Resident #52 has a pressure ulcer, unstageable at this time, as a result of quadriplegia. It is appropriate to proceed with the planned procedure of debridement with wound closure of left buttock. The wound measured three cm in length by one-point six cm in width and had eschar flush to skin level. The post debridement measurements before primary closure of the wound were three-point eight cm in length, two cm in width, and two-point five cm in depth. The area was injected with lidocaine (a local anesthesia) and the entire eschar area was sharply debrided with a scalpel. The underneath tissue appeared as non-healthy appearing fat, rather chronically ischemic. The tissue was sharply debrided to healthy fat, thankfully somewhat superficial. MD #403 attempted a primary closure, and a Penrose drain (a soft, flat, flexible latex tube used in surgery to promote drainage of fluids, like blood or lymph, from the surgical site) was placed into the wound bed. A progress note dated 03/21/25 revealed the left gluteus wound was deteriorating with dehiscence (partial or complete separation of a surgical wound). The incision measured five cm in length and had a heavy amount of seropurulent drainage. The dressing had a moderate amount of dark tan drainage and MD #403 was notified. A progress note dated 03/21/25, written by CNP #405, revealed nursing staff reported an increase in drainage and a reddened area to the top left of the wound. The wound appeared to have maceration to the superior lateral portion. The wound measured approximately four-point five cm in length, one-point three cm in width and two cm in depth. The wound bed had granulation tissue with little residual non-healthy fat. The sutures were removed as well as the Penrose drain. The wound was rinsed with peroxide and packed with one-inch iodoform, covered with gauze. A new order to apply zinc oxide cream to the macerated skin and change the iodoform packing daily with a dry dressing. Resident #52 was hospitalized from 03/25/25 to 03/27/25 and 04/03/25 to 04/11/25. Review of the hospital records revealed on 04/04/25, a sharp debridement of skin, subcutaneous fat, muscle mass and fascia were performed. Resident #52 has had continual progression of wound compromise from the initial surgical debridement on 03/13/25 and non-healing due to stool soiling the wound, causing persistent wound infection. Resident #52 needed another debridement and a diverting colostomy for wound care management. The Eliquis will need to be held. Resident #52 returned to the facility on [DATE] and the wound has been healing. Interview on 05/08/25 at 2:50 P.M. with the DON confirmed there was no physician order in place to treat Resident #52's left buttock wound from 01/27/25 to 02/19/25. The DON stated she was sure she had measured the wound and described the wound to the MD and received the order but apparently forgot to write it on 01/27/25. Interview on 05/08/25 at 3:00 P.M. with the Regional Director of Clinical Services (RDCS) #400 stated the dressing to the left buttock wound would have been changed due to Resident #52 being incontinent but confirmed there was no documentation located in Resident #52's medical record that a dressing was changed. Interview on 05/08/25 at 3:20 P.M. with MD #401 revealed he had not given the order to clean the left buttock wound as he had not been on-call that week and was unaware of Resident #52 having a wound. MD #401 stated he normally relies on the wound nurse for recommendations for treatments and was surprised to learn the fact the facility did not have a wound nurse. MD #401 stated cleaning the wound with soap and water and applying a foam border dressing was not an inappropriate treatment to treat Resident #52's wound. Review of the NPUAP guidelines dated 2014 revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Ongoing assessment of the skin was necessary to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. Review of the policy titled Pressure Ulcer Policy dated 04/29/16, revealed the wound will be monitored at least weekly and should have documentation including location and staging, size, drainage, pain and description of wound bed and surrounding tissue.

Based on record review and staff interviews, the facility failed to have a Registered Nurse (RN) on duty for eight consecutive hours every day. This had the potential to affect all 53 residents residing in the facility. Findings include: Review of the staffing schedules dated 04/27/25 through 05/03/25 revealed the facility did not have an RN scheduled on 05/03/25. The staffing schedules dated 04/19/24 through 04/20/24 revealed the facility did not have an RN scheduled on 04/19/25. Interview on 05/07/25 at 12:20 P.M. and 1:40 P.M. with the Director of Nursing (DON) stated she (DON) worked 05/03/25 between the hours of 2:30 P.M. and 9:00 P.M., for a total of 6.5 hours. The DON verified there were no RN hours on 04/19/25. Interview on 05/07/25 at 12:10 P.M. with Administrator verified there was only 6.5 RN hours who worked on 05/23/25.

Based on observation, record review, and staff interview, the facility failed to ensure oxygen was provided with humidification per physician order. This affected one (#108) of one resident reviewed for oxygen use. The facility identified three (#13, #26, and #28) additional residents who received oxygen with humidification. The facility census was 53. Findings include: Review of the medical record for Resident #108 revealed an admitted [DATE] and a discharge date upon death of 05/07/25. Diagnoses included lung cancer and chronic obstructive pulmonary disease. Resident #108 was admitted to the facility under the care of Hospice. Review of the Clinical Admission Assessment, dated 05/01/25, revealed Resident #108 was alert and oriented to person, place, and time. Resident #108 received oxygen via nasal cannula with humidification. Review of the physician order initiated 05/02/25 revealed Resident #108 received oxygen at two liters per minute via nasal cannula. The physician order dated 05/02/25 revealed Resident #108's oxygen concentrator should be wiped down weekly and the water jug should be changed weekly. Observation on 05/06/25 at 9:14 A.M. revealed Resident #108 lying in bed, wearing a nasal cannula and the oxygen concentrator had no humidifier attached. Interview and observation on 05/06/25 at 3:16 P.M. with Certified Nursing Assistant (CNA) #353 revealed Resident #108 lying in bed awake, wearing a nasal cannula. CNA #353 confirmed the oxygen concentrator had no humidifier attached. Interview and observation on 05/07/25 at 9:39 P.M. with CNA #381 revealed Resident #108 lying in bed, wearing a nasal cannula. CNA #381 confirmed the oxygen concentrator had no humidifier attached. Interview on 05/07/25 at 9:52 A.M. with Licensed Practical Nurse (LPN) #371 confirmed Resident #108 had a physician order for oxygen with humidification and confirmed she added humidification to his concentrator after talking with CNA #381.

Based on observation, staff interview, and policy reviews, the facility failed to maintain a clean, sanitary kitchen area and store food appropriately. This had the potential to affect 41 (excluding #92) of 41 residents who received meals in the facility. The facility identified Resident #92 as receiving no food from the kitchen. The facility census was 42. Findings include: Observation of the kitchen, on 12/04/22 at 8:15 A.M., revealed debris and a build up of dirt on the floor of the storage area, kitchen, refrigerator, and freezer. Observation of kitchen storage surface areas revealed a heavy build up of dust and dirt. Observation of the refrigerator revealed steam table containers of cooked food including sloppy [NAME], gravy, chicken noodle soup, and cream of chicken unlabeled and undated. Additional food unlabeled and undated in the refrigerator included two eggs in a container. Subsequent observations of the freezer revealed two rolls of beef on freezer floor. Interview on 12/04/22 at 8:23 A.M., with Dietary Staff #353 verified the kitchen, storage area, refrigerator, and freezer were dirty and in need of cleaning. Dietary Staff #353 verified the unlabeled and undated food in the refrigerator and beef on the freezer floor. Review of the policy titled, Sanitation, dated February 2016, verified the dish room, kitchen, and storage area will be kept clean, and free from litter and rubbish. All utensils, counters, shelves, and equipment will be kept clean, maintained in good repair. Review of the policy titled, Food Storage, dated January 2018, revealed food storage areas will be clean at all times. All foods stored in walk-in refrigerators and freezers will be stored above the floor on shelves, racks, dollies, or other surfaces that facilitate thorough cleaning. Previously cooked foods should be stored in shallow pans, covered, double dated (day in, day out) and placed in the cooler immediately.

Based on observation, record review, staff interviews, the facility failed to ensure a base line care plan included oxygen usage and respiratory treatments. This affected one (#196) of 14 residents reviewed for care plans. The facility census was 42. Findings include: Review of medical record for Resident #196 revealed an admitted [DATE], with diagnoses including: dementia with agitation, respiratory failure with hypoxia, hyperlipidemia, chronic obstructive pulmonary disease (COPD), hypotension, unspecified body in respiratory tract part unspecified causing other injury, cardiomyopathy, paralysis of vocal cords and larynx, allergic rhinitis due to animal hair and dander, atherosclerotic heart disease of native coronary artery, hypertension, depression, anxiety, personal history of malignant neoplasm of breast, insomnia, and gastro-esophageal reflux disease. Review of base line care plan dated 11/30/22 revealed no care plan for oxygen therapy or respiratory issue. Review of physician orders for Resident #196 revealed order for humidified oxygen at two to five liters (L) via nasal cannula (nc) per concentrator to keep oxygen saturation greater than 90 percent (%), albuterol sulfate (hydro fluoroalkane) HFA inhalation aerosol solution 108 (90 base) microgram (mcg)/ACT- two puffs orally every six hours as needed for shortness of breath (SOB)/wheezing, albuterol sulfate nebulization solution (2.5 milligrams (mg)/three milliliters(ml)) 0.083% take one unit dose per aerosol every four hours as needed for dyspnea (SOB), budesonide inhalation suspension 0.5 mg/2 ml inhale 2 ml orally twice daily for COPD, elevate head of bed to reduce SOB while lying flat as tolerated, and yupelri inhalation solution 175 mcg/3 ml daily for COPD. Observation on 12/04/22 at 9:49 A.M., of Resident #196 revealed the resident had on oxygen at two liters via nasal cannula. Resident #196 appeared anxious and stated I need oxygen. Interview on 12/04/22 at 4:07 P.M., with Registered Nurse (RN) #366 stated Resident #196 needed oxygen and would call out she needed oxygen often. RN #366 stated she had taken the resident's vital signs and the oxygen level was 98% on two liters. Interview on 12/05/22 at 1:21 P.M., with the Director of Nursing (DON) verified Resident #196 did not have a care plan for oxygen use or respiratory issue. DON verified resident had oxygen order on admission and respiratory treatments.

Based on medical record review, observations, staff interviews, and policy review, the facility failed to implement a fall care plan intervention to prevent falls. This affected one (#16) of four residents reviewed for falls. The facility census was 42. Findings include: Review of the medical record for Resident #16 revealed an admitted [DATE]. Diagnoses included: other nonspecific abnormal finding of lung field, anxiety disorder, depression, essential (primary) hypertension, hyperlipidemia, type two diabetes mellitus with hyperglycemia, and insomnia. Review of the form titled Nursing Fall Assessment Review, dated 09/20/22, revealed the resident was at moderate risk for falls. Review of the care plan, updated 09/21/22, revealed the resident was care planned for falls with an intervention included the bed to be in the lowest position with mats to the floor on each side of the bed. Review of the Minimum Data Set (MDS) assessment, dated 09/27/22, revealed the resident was cognitively intact. Observation on 12/04/22 at 2:20 P.M., revealed Resident #16 was in bed, the fall mat on the resident's right side was laying on the floor against the all and not next to the bed. Interview on 12/04/22 at 2:25 P.M., with State tested Nursing Assistant (STNA) #180 verified the fall mat was not in the proper location. Observation on 12/06/22 at 11:50 A.M., revealed Resident #16 was in bed, the fall mat on the resident's right side was laying on the floor against the wall and not next to the bed. Interview on 12/06/22 at 11:58 A.M., with the Director of Nursing (DON) verified the fall mat was not in the proper location. Review of the policy titled, Fall Reduction Policy, revised April 2016, revealed the facility will identify residents at risk for falls and to implement a fall reduction program to reduce the risk of falls and possible injury.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure a resident's nutritional needs were met as care planned. This affected one (#26) of three residents reviewed for meals. The facility census were 42. Findings include: Review of the medical record review for Resident #26 revealed an admitted [DATE]. Diagnoses included: schizoaffective disorder, liver disease, obstructive sleep apnea, major depressive disorder recurrent, cognitive communication deficit, dementia in other diseases classified elsewhere with agitation, anorexia, chronic kidney disease, essential (primary) hypertension, bipolar disorder current episode depressed, hyperlipidemia, Alzheimer's disease. Review of monthly physician orders revealed an order dated 08/05/22 for regular diet, regular texture and regular consistency liquids. Review of the Minimum Data Set (MDS) assessment, dated 11/01/22, revealed the resident was moderately cognitively impaired. Review of the care plan, reviewed on 11/15/22, revealed Resident #26 was care planned for impaired nutritional status with interventions including to provide diet as ordered with regular diet, regular texture, regular consistency liquids. Provide double portions entree every meal and give ice cream lunch and supper meals for weight loss. Review of meal ticket revealed, dated lunch 12/06/22, revealed Resident #26 received regular diet, regular texture, and thin liquids. The meal included creamy potato soup, one fried bologna sandwich, condiment, milk, and double chocolate chip cookie. Observation on 12/06/22 at 11:03 A.M., of Resident #26 meal revealed a single bologna sandwich and no ice cream. Interview on 12/06/22 at 11:05 A.M., with State tested Nursing Assistant (STNA) #322 verified Resident #26 did not have double portions or ice cream as care planned. Interview on 12/06/22 at 11:36 A.M., with Dietary Technician #314 verified Resident #26 should be receiving a double entree at every meal and ice cream twice a day. Review of the policy titled, Nutrition Policy, dated April 2016, revealed the facility will ensure that a resident maintains acceptable parameters of nutritional status.

Based on medical record review, review of facility policy, staff interview and review of the Notice of Medicare Non-Coverage instructions, the facility failed to ensure residents and resident representatives were provided with advance notice of non-coverage of Medicare Part A skilled services. This affected three (#24, #112, #113) of four residents reviewed for beneficiary notices. The facility identified five residents discharged from skilled services in the last six months. The facility census was 62. Findings include: 1. Review of the closed medical record for Resident #113 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Further review of the medical record revealed the resident was discharged from the facility on 06/07/19. Review of a Skilled Nursing Facility (SNF) Protection Notification Review revealed Resident #113's skilled services started on 05/07/19 and the last covered day of skilled services was 06/05/19. The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. It revealed a Skilled Nursing Facility Advanced beneficiary notice (SNFABN) was completed and a Notice of Medicare Non-coverage letter was provided. Review of the Notice of Medicare Non-Coverage form revealed skilled services were to end on 06/05/19. Telephonic notification on 06/03/19 at 1:30 P.M. revealed Case Manager #125 explained the notice of non-coverage to the family and informed them of their right to appeal. The form was un-signed by the resident or family. Review of the SNFABN form revealed dated 06/03/19 revealed Case Manager #125 informed the resident's family of the skilled services being discontinued and of the need for out of pocket payments if they chose to continue with skilled services and provided them the options available to them. The form was unsigned by the resident or family. Interview with Case Manager #125 on 07/29/19 at 3:30 P.M. verified she had provided information regarding Medicare skilled services being completed but did not send the SNFABN or the Notice of Medicare Non-Coverage to the family to be signed. 2. Review of the closed medical record for Resident #112 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Further review of the medical record revealed the resident was discharged from the facility on 06/17/19. Review of a SNF Beneficiary Protection Notification Review revealed skilled services for Resident #112 began on 04/15/19 and the last covered day was to be 05/10/19. It revealed a Notice of Medicare Non-Coverage form was provided. Review of the Notice of Medicare Non-coverage form revealed skilled services for Resident #112 would end on 05/10/19. Telephone notification was provided on 05/07/19 by Case Manager #125 of the resident's last covered day to be 05/11/19. The form was not signed by the resident or family member. Interview with Case Manager #125 on 07/29/19 at 3:30 P.M. verified she had provided information regarding Medicare skilled services being completed but did not send the Notice of Medicare Non-Coverage to the family to be signed. 3. Review of the medical record for Resident #24 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a SNF Beneficiary Protection Notification Review revealed skilled services for Resident #24 began on 03/01/19 and the last covered day was to be 03/21/19. It revealed a Notice of Medicare Non-Coverage form was provided to the family. Review of the Notice of Medicare Non-coverage form revealed skilled services for Resident #24 would end on 03/21/19. Telephone notification was provided on 03/19/19 by Case Manager #125 of the resident's last covered day to be 03/21/19. The form was not signed by the resident or family member. Interview with Case Manager #125 on 07/29/19 at 3:30 P.M. verified she had provided information regarding Medicare skilled services being completed but did not send the Notice of Medicare Non-Coverage to the family to be signed. Review of facility policy SNF-Beneficiary Notice Requirements dated (YEAR) revealed the facility was obligated to inform Medicare Part A and B beneficiaries about specific rights related to billing. The facility must notify the resident or his /her responsible party in writing in advance and explain why the services may not be covered, the beneficiary's potential liability for payment for the non-covered services, the beneficiary right to have a claim submitted to Medicare and the beneficiary's right to appeal. The notification requirement was to be met with the use of the SNFABN. The facility was to issue the Notice of Medicare Provider Non-Coverage form, no later than two days before termination of all Medicare Part A services Review of the Form Instructions for the Notice of Medicare Non-Coverage revealed if the provider is personally unable to deliver a Notice of Medicare Non-Coverage to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee ' s services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. When direct phone contact cannot be made, send the notice to the representative by certified mail, return receipt requested.

Based on observation, staff interview, and resident record review, the facility failed to ensure staff maintained aseptic technique when de-accessing a central line port-a-catheter connected to a Huber needle set. This affected one (#262) of one resident reviewed for intravenous medications use. Additionally, the facility failed to maintain infection control practices while administering oral medications. This affected one (#263) of seven residents observed for medication administration. The census was 62. Findings include: 1. Review of the medical record for Resident #262 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Observation on 07/29/19 at 03:36 P.M. with Registered Nurse (RN) #400 of Resident #262 during disconnection of intravenous line tubing from a central line port-a-catheter connected to a Huber needle set. RN #400 had gloved hands and opened the night stand drawer with the gloved hands, reached in the drawer, and touched items in the drawer to pull out an alcohol prep pad. Without changing gloves, RN #400 then opened the alcohol prep pad and picked up the central line tubing to disconnect from the Huber needless injection cap. The surveyor ask RN #400 about her gloves and that they were contaminated/dirty. RN #400 then proceeded to don new gloves and disconnected the intravenous line tubing. Interview on 07/29/19 at 03:38 P.M. with the RN #400 verified the gloves were dirty from touching the night stand drawer and revealed she should have changed the gloves prior to touching the central line. 2. Observation on 07/31/19 at 8:44 A.M. of medication administration with RN #200 for Resident #263 revealed RN #200 dropped a pill on the medication cart. RN #200 picked the dropped pill up with her bare hands and put the pill in the medication cup. Further observation revealed RN #200 administered the medication to Resident #263. Interview on 07/31/19 at 8:57 A.M. with RN #200 verified the nurse picked up the medication with bare fingers/hands. The RN revealed she should have used gloves to pick up the pill off the cart. Interview on 07/31/19 at 2:51 P.M. with the Director of Nursing (DON) verified RN #200 revealed to her she had dropped a pill on the medication cart and administered the medication to Resident #263. The DON further verified proper practice should have been for RN #200 to discard the medication and replace with an uncontaminated pill.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure medication regimen reviews (MRRs) were reviewed by the physician in a timely manner and failed to ensure the facility policy included time frames for processing non-urgent MRRs. Additionally, the facility failed to ensure pharmacist recommendations were provided to the facility in a consistent timely manner. This affected four (Resident #22, #36, #43, and #51) of five residents reviewed for unnecessary medications. This had the potential to affect all 64 residents. Findings include: 1. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Note to Attending Physician/Prescriber for the MRR, dated 10/06/17, revealed the pharmacist noted Resident #43 had an order for [REDACTED]. The physician did not respond to the recommendations until 11/16/17 (41 days later). Interview on 10/03/18 at 4:54 P.M. with Director of Nursing (DON) stated the physician will not review pharmacy MRR unless they are seeing the resident. The DON verified sometimes the facility does not receive the MRRs from the pharmacist for two weeks or more. The DON verified the pharmacy recommendations for Resident #43 were issued on 10/06/18 and not reviewed or addressed by the physician until 11/16/17. 2. Review of the medical record for Resident #36 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Note To Attending Physician/Prescriber for the Medication Regimen Review, dated 12/13/17, revealed the pharmacist recommended to change [MEDICATION NAME] sulfate and switch to multivitamin plus iron for maintenance supplementation. The physician wrote she agreed with the recommendation on 03/01/18 (78 days later). Interview with the DON on 10/03/18 at 4:54 P.M. verified the pharmacy recommendations for Resident #36, dated 12/13/17 and was not addressed by the physician until 03/01/18. Further interview with the DON on 10/04/18 at 2:45 P.M. verified the pharmacist was at the facility and reviewed the medications for Resident #36 on 12/13/17. She stated the recommendations were not received by the facility until 12/29/17 and were not printed for follow up until at least 01/2018. 3. Review of the medical record for Resident #51 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a Note to Attending Physician/Prescriber for the Medication Regimen review, dated 10/06/17, revealed the pharmacist recommended adding a lipid panel to (MONTH) (YEAR) labs and yearly. The physician agreed and signed the recommendation on 11/16/17 (41 days later). Interview with the Director of Nursing on 10/03/18 at 4:54 P.M. verified the physician did not respond to the recommendation until 11/16/17. She stated the physician does not review the MRR until the resident is physically assessed by the physician. 4. Review of Resident #22's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the resident's Note To Attending Physician/Prescriber for the Medication Regimen Review, dated 12/13/17, revealed the pharmacist recommended a dosage to decrease the resident's antidepressant medications ([MEDICATION NAME] and [MEDICATION NAME]). The physician agreed with the recommendation two months later on 02/16/18 and wrote a dosage reduction of [MEDICATION NAME]. Interview with the DON on 10/03/18 at 4:54 P.M. verified Resident #22's pharmacy recommendation dated 12/16/17 was not addressed by the physician until 02/16/18. Further interview with the DON on 10/04/18 at 2:45 P.M. verified the pharmacist reviewed the medications for Resident #22 on 12/13/17, however, the MRR was not received by the facility until 12/29/17. She stated the physician does not review the MRRs unless the physician physically sees the resident. Review of the facility policy titled Pharmaceutical Services dated 03/2017 revealed the facility must provide routine and emergency drugs and biological to its residents. The drug regimen review must be reviewed at least once a month by a licensed pharmacist. The pharmacist must report any irregularities to the attending physician, the facility's Medical Director, and the Director of Nursing. Irregularities that need immediate attention will be verbally communicated to the responsible nurse for that resident. The policy was silent to addressing times frames for non-urgent irregularities.

Based on medical record review, interview and facility policy review, the facility failed to routinely assess and monitor a skin condition for a resident. This affected one (#43) of one residents reviewed for skin condition. The facility identified seven residents identified as having any skin alterations. The facility census was 64. Findings include: Review of the medical record revealed Resident #43 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]., [MEDICAL CONDITION] disorder and [MEDICAL CONDITION] disorder. Review of the Nursing Wound Documentation Record, dated 08/15/18 at 1:00 P.M., revealed Resident #43 had an open area on her left buttock measuring 1.5 centimeters (cm.) by 1.5 cm and an unknown depth. The wound documentation identified the area as a stage two pressure wound (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough and also identified it as an abrasion/scab. The narrative included the wound appeared to be an abrasion that was scabbed. There was no odor. Since it was scabbed, there was no way of knowing if there was any tunneling. Numerous pink areas were also observed in that area, but they blanch so far. Review of the nurse's progress notes revealed on 08/15/18 at 7:07 P.M. revealed there was an area on the right buttock and redness noted along the perimeter of the dressing from the tape. The progress note dated 08/18/18 at 10:19 P.M. the nurse stated when the coccyx dressing was changed, a scabbed area remained from the tape. There were no signs or symptoms of infection noted. The progress note, dated 08/19/2018 at 10:33 P.M., documented when the coccyx dressing was changed, a scabbed area remained from the tape. There were no signs or symptoms of infection noted. The progress note, dated 08/20/2018 at 9:35 P.M., revealed the dressing changed to coccyx was completed per order. A small area was noted to right buttocks where tape caught skin and a scabbed area remained. No drainage was noted on the old dressing and no signs or symptoms of infection were noted. Further review of the nurse's progress notes until 10/04/18 and the Nursing Wound Documentation Record from 08/15/18 until 10/04/18 revealed there was no further information documented regarding the injury to Resident #43's right buttock. The documentation did not include at least weekly assessments of the wound location, type, color, measurements, drainage and other characteristics. There was no documentation indicating if the area was ever healed. Interview with Registered Nurse (RN) #200 on 10/04/18 at 8:43 A.M. verified the facility nurses document wounds other than pressure wound in the nurse progress notes. RN #200 verified Resident #43 has a wound on her right buttock. RN #200 verified the documentation that was in the progress notes regarding the wound did not include thorough assessments and that the wound was never identified as healed in the medical record. Review of the facility policy titled Skin Assessment, dated 11/2007, revealed the purpose was to evaluate the resident's overall skin condition and identify risk factors and to identify and evaluate wounds and determine appropriate treatment and response to treatment. Assessments should be done on admission, weekly for four weeks and any time a resident complains of itching, rash or discomfort. Daily observation were done during bathing and dressing. The following should be noted and described: 1. Location 2. Type of lesion/rash/blister 3. Color 4. Size, stage if pressure wound 5. Shape and distribution 6. Crusting/drainage 7. Tendency to bleed 8. Presence or absence of itching/pain

Based on observation, staff interview and review of weekly water temperature monitoring log, the facility failed to ensure hot water temperatures were maintained at a safe level. This had the potential to affect 19 of 57 residents (#2, #15, #21, #6, #18, #85, #82, #5, #53, #76, #71, #43, #16, #2, #4, #34, #1, #3, and #17) residing in the facility. Findings include: Observation on 06/20/16 at 3:30 P.M. revealed hot water temperatures exceeding 120 degrees Fahrenheit. On 06/20/16 between 3:30 P.M. and 3:45 P.M., rooms #24, #23, #22, #28, #25, #26, #21 and #19 hot water was measured at 131 degrees Fahrenheit, rooms #29, #30, and #20 hot water was measured at 130 degrees Fahrenheit, and room #18 hot water was measured at 129 degrees Fahrenheit. On 06/20/16, interview with Maintenance Director #1 at 3:45 P.M. verified the hot water temperatures inside rooms #24, #23, #22, #28, #25, #26, #21, #19, #29, #30, #20, and #18 were all above 120 degrees Fahrenheit. Maintenance Director #1 was unaware the hot water temperatures exceeded the 120 degree Fahrenheit limit and stated the hot water temperatures are checked once weekly on all halls. Maintenance Director #1 stated he had never had any hot water temperatures as high as the readings on 06/20/16, and stated he would look into what was causing the high hot water temperatures right away. Interview on 06/20/16 with Director of Nursing #1 at 3:50 P.M. verified there had not been any residents who were burned by hot water in the facility. On 06/20/16 at 4:15 P.M., interview with Maintenance Director #1 stated adjustments had been made to water temperatures and are currently reading below 120 degrees Fahrenheit in rooms #24, #23, #22, #28, #25, #26, #21, #19, #29, #30, #20, and #18. Review of facility hot water temperature logs documented the water temperatures recorded weekly between 05/29/16 and 06/16/16 were between 107 degrees Fahrenheit and 113 degrees Fahrenheit. On 06/20/16 between 4:15 P.M. and 4:30 P.M., observation of hot water temperatures in resident rooms #24, #23, #22, #28, #25, #26, #21, #19, #29, #30, #20, and #18, with Maintenance Director #1, noted hot water temperatures between 109 degrees Fahrenheit and 111 degrees Fahrenheit. Interview with Maintenance Director during these observations stated the value to the hot water line was stuck open and had to be adjusted. Interview with Maintenance Director #1 on 06/23/16 at 11:50 A.M., stated he had been monitoring water temperatures on all halls in the facility between 06/20/16 and 06/23/16 and were consistently at or below 120 degrees Fahrenheit. Review of facility hot water temperature logs documented water temperatures recorded between 06/20/16 and 06/23/16 were between 109 degrees Fahrenheit and 113 degrees Fahrenheit.

Based on observation, staff interview, and medical record review, the facility failed to notify the physician when insulin was not administered per the physician's orders [REDACTED].#3) of four residents observed during medication observation. The facility identified 14 residents currently receiving insulin. The facility census was 57 Findings include: Review of Resident #3's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED]. The resident also had an order dated 06/02/16 for [MEDICATION NAME](short acting mealtime insulin) per sliding scale. Review of the resident's Medication Administration Record [REDACTED]. Continued review of the MAR indicated [REDACTED]. The resident also received fifteen units of [MEDICATION NAME]at breakfast and lunch. Medication observation was observed on 06/22/16 at 8:50 A.M. with Licensed Practical Nurse (LPN) #50. Resident #3 received 26 units of Toujeo insulin and fifteen units of [MEDICATION NAME] insulin. Interview with LPN #50 on 06/02/16 at 8:50 A.M. revealed Resident #3 only had 26 of the 88 ordered units of Toujeo insulin left. She stated she did not have a refill for the resident and would ask the pharmacy to drop ship it to the facility. At 3:10 P.M. LPN #50 stated she had not received Resident #3's Toujeo insulin from the pharmacy. She stated she did not notify the physician Resident #3 did not receive the ordered amount of Toujeo insulin during her morning medication administration. Interview with the Director of Nursing (DON) on 06/22/16 at 3:20 P.M. revealed she would expect the nursing staff to notify the physician if a resident's insulin was not available. She further stated the facility did not have a policy on notification.

Based on medical record review, and staff interview, the facility failed to ensure non-pharmacological interventions were attempted prior to administering as needed anti-anxiety medications. This affected one (#78) of five residents reviewed for unnecessary medications. The facility identified 19 residents receiving as needed antiquity medications. The facility census was 57. Findings include: Review of Resident #78's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's comprehensive assessment revealed the resident had severely impaired cognition. Review of the resident's physician's orders [REDACTED]. There was no documentation of non-pharmacological interventions attempted prior to administration for eleven of the seventeen doses as follows: two doses on 05/02/16, 05/06/16, two doses on 05/16/16, 05/18/16, 05/21/16, 05/22/16, two doses on 05/24/16,and 05/25/16. Review of the June 2016 MAR indicated [REDACTED]. There was no documentation of non-pharmacological interventions attempted prior to administration for five of the nine doses as follows: 06/01/16, 06/03/16, 06/05/16, 06/17/16, and 06/18/16. Interview with the Director of Nursing (DON) on 06/22/16 at 3:19 P.M. verified non-pharmacological interventions were not documented for the above dates. She stated the nursing staff was expected to attempt and document non-pharmacological interventions prior to administering prn medications. She further stated the facility did not have a policy on documentation of non-pharmacological interventions.

Based on observation, staff interview, medical record review, and review of facility policy, the facility failed to ensure insulin was administered as ordered by the physician. This affected one (#3) of four residents observed during medication observation. The facility identified 14 residents currently receiving insulin. The facility census was 57. Findings include: Review of Resident #3's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED]. The resident also had an order dated 06/02/16 for [MEDICATION NAME](short acting mealtime insulin) per sliding scale. Review of the resident's Medication Administration Record [REDACTED]. Continued review of the MAR indicated [REDACTED]. The resident also received fifteen units of [MEDICATION NAME]at breakfast and lunch. Medication observation was observed on 06/22/16 at 8:50 A.M. with Licensed Practical Nurse (LPN) #50. Resident #3 received 26 units of Toujeo insulin and fifteen units of [MEDICATION NAME] insulin. Interview with LPN #50 on 06/2/16 at 8:50 A.M. revealed Resident #3 only had 26 of the 88 ordered units of Toujeo insulin left. She stated she did not have a refill for the resident and would ask the pharmacy to drop ship it to the facility. Interview with LPN #50 on 06/02/16 at 3:10 P.M. revealed she had not received Resident #3's Toujeo insulin from the pharmacy. She stated she did not notify the physician Resident #3 did not receive the ordered amount of Toujeo insulin during her morning medication administration. Interview with the Director of Nursing (DON) on 06/22/16 at 3:20 P.M. revealed she would expect the nursing staff to notify the physician if a resident's insulin was not available. Review of a facility policy titled Medication Administration dated 04/13 revealed the nurse was to ensure medication was given in the correct dosage.

Based on observation, resident interview, staff interview, and policy review, the facility failed to provide comfortable and safe temperature levels on the Laurel Loft unit. This affected 16(#13, #14, #19, #22, #23, #33, #41, #42, #60, #69, #71, #74, #87, #88, #95, and #112) of 16 residents living in the Laurel Loft unit. The facility census was 76. Findings include: Interview with Resident #42 on 07/20/15 at 11:40 A.M., stated it was always cold in her unit (Laurel Loft). Observation at the time of the interview revealed the common area of the unit felt cold. Observation on 07/20/15 at 1:55 P.M., revealed Resident #74 in the common area seated on a chair near the nurse's station wearing a heavy coat. Resident # 87 was also sitting in a chair near the nurse's station covered with a blanket. Observations on 07/21/2015 at 11:09 A.M., of the locked unit in Laurel Loft, the thermostat on the wall in the front hall was set at approximately 72 degrees. The temperature read approximately 68 degrees. The thermostat was an older style which had only 50, 60, 70 and 80 degrees marked and a hash-mark for 55, 65 and 75. At 1:50 P.M., the temperature reading on Laurel Loft old thermostat remained at approximately 68 degrees. The ambient temperature continued to feel uncomfortably low. Observations on 07/21/2015 at 2:57 P.M., of the thermostat temperature on the wall on Laurel Loft unit revealed the temperature was 68 degrees. During the observation, State tested Nurse Aid (STNA) #300 was passing by. She made an unsolicited comment to the surveyor tomorrow you'll have to wear a coat and earmuffs. On 07/22/2015 11:17 A.M., the surveyor was reviewing a resident chart with Licensed Practical Nurse (LPN) #302 in the nurse's station in Laurel Loft. LPN #302 made an unsolicited comment that it's cold back here. It will freeze you out. Observation in the Laurel Loft dining room on 07/22/2015 at 11:24 A.M., revealed eleven residents were present eating lunch. Only one resident (#41) was in short sleeves. Three residents (#60, #19 and #112) were in sweat-shirts. Three residents (#13, #22 and # 60) were wearing 'hoody' jackets. Two residents (#71 and #74) were wearing long sleeved shirt and covered with a blanket. Two residents (#14 and #87) were wearing long sleeved shirts. Resident #95 was wearing a heavy coat. Attempted interview with Residents #41, #13, #95, #87, #14, #112 and #60 on 07/22/15 during lunch failed. None of these eight residents verbalized a response when asked if they were warm enough. Interview with Resident #74 on 07/22/15 at 11:34 A.M., verified she was wearing a jacket because it is cold on Laurel Loft. She stated the jacket takes the chill away. Interview with Resident # 71 on 07/22/2015 at 11:38 A.M., she stated, it is always cold on Laurel Loft. She was wearing long sleeved flannel-type shirt over a T-shirt and a blanket across her lap. Interview with Resident #22 on 07/22/2015 at 11:41 A.M. he stated it is cold back here all the time. He said you can tell it is cold because everyone was wearing long sleeves and coat. He stated the thermostat sometimes reads below 70 degrees Interview on 07/22/2015 at 11:49 A.M., with STNA #303, stated it is cold up in the front part of Laurels Loft. STNA # 303 denied it was cold but stated she liked the cool temperature. She stated if the residents complain of being cold, they get them a blanket or sweater. She stated the maintenance man was on the unit this morning and adjusted the thermostat in the front hall of Laurel Loft because of a complaint that it was too cold on Laurel Loft. STNA #303 further stated some of the residents are always cold and some of the residents wear a coat all the time. Interview on 07/22/2015 at 11:53 A.M., with Registered Nurse (RN) #304 stated it gets chilly sometimes, mostly in the front part of Laurel Loft. She verified they provide blankets or jackets to residents if they say they are cold. Observation on 07/22/15 at 5:00 P.M.,in the front hall of Laurel Loft the old style thermostat was set at approximately 77 degrees. The temperature reading was approximately 68 degrees. Interview with Maintenance Supervisor (MS) #301 on 07/22/15 at 5:14 P.M., revealed he does not monitor the facility temperatures. He stated he tries to maintain the temperatures between 71-81 degrees. He verified the temperatures were too cold on Laurel Loft today. He verified he had adjusted the thermostat twice today and he had increased the thermostat setting on Laurel Loft yesterday too because the Activities person and the nurse told him it was cold back there. He stated every resident room had their own heating/air conditioning unit and the residents can adjust the temperatures in their rooms. He stated the halls and common areas are cooled by roof-top units. Each hall has its own unit and its own thermostat. He verified the thermostat in the front hall of Laurel loft was set at 77 degrees and the temperature reading on the thermostat was approximately 68 degrees. MS #301 checked the thermometer provided by the surveyor and verified it was reading approximately 66 degrees. MS #301 then provided a facility digital laser thermometer. He checked the temperature pointing the lacer toward the floor, a bench, the wall and toward the ceiling. The temperature reading obtained varied between 63 degrees on the floor and 69 degrees on the ceiling. He verified all the temperatures discussed were below 71 degrees. Interview on 07/23/15 at 10:38 A.M., with MS # 301 the thermostat on the front hall of Laurel Loft had been changed this morning. He verified that the old one was not working. Review of the facility policy titled Extreme Temperature Conditions dated 2005, revealed the facility temperature should be maintained between 71 degrees and 81 degrees. The Manor must monitor the air temperature, the residents' health status and take preventive action when the insider temperature of the building is outside this range. The facility did not follow their policy when the temperatures were not maintained above 71 degrees. The facility did not monitor inside temperatures.

Based on surveyor observation, staff interview, and review of the facility policy for left overs, it was determined the facility failed to ensure proper labeling and dating were present on food items in the reach in cooler and walk-in cooler. This had the potential to affect 95 residents served from the kitchen. Findings include: During the initial tour of the kitchen on 10/11/11 at 8:30 A.M., the reach in cooler had a container of a brown substance that was not labeled to identify the contents or the date placed in the cooler. There was also a tray of individual serving cups that contained the same brown substance. There was no date or identifying information present. There was also a container of a mixture that appeared to be peanut butter and jelly. The container was labeled "Jelly" and dated 09/30/11. There were also two trays containing individual serving portions of peaches. These trays were not dated. The walk-in cooler had a plastic container of a thickened white liquid without a date or identifying information. Interview with Cook #1, at the time of the observation, indicated the brown substance was a BAP mixture that consisted of bran, applesauce and prunes. This is mixed by the facility dietary staff every few days. Cook #1 was not sure when the mixture was prepared. Cook #1 also indicated the peanut butter and jelly mixture is prepared by the facility staff and the peaches were leftovers from the prior days meal. Interview with Dietary Manager #2, at the time of the observation, indicated they keep the peanut butter and jelly mixture for about a week and leftovers should be dated when placed in the cooler. She also stated she did not know when the BAP was prepared. She verified the walk-in cooler contained one carton of thickened milk, not dated to identify when it was prepared. The dietary manager indicated the thickened white liquid was milk which gets prepared a day before each days use. Dietary Manager #2 further verified the lack of dates and identifying information on the containers of BAP, peaches, and thickened milk. The dietary manager also removed the peanut butter and jelly mixture, indicating it was outdated. Review of the facility's undated policy "Leftovers" indicated all leftovers for storage in the refrigerator are to be put in storage containers, labeled and dated. The policy also notes that all leftovers are to be discarded after three days. The facility identified 95 residents who receive their meals from the kitchen.

Based on medical record review, staff interview and review of facility policy, it was determined the facility failed to report an injury of unknown origin to the State Agency (ODH) as required. This affected one (#118) of one resident reviewed for injuries of unknown origin. The facility identified only one resident with an injury of unknown origin in the past three months. The facility census was 98. Findings include: Review of Closed Resident (CR) #118's medical record revealed the resident was admitted to the facility on [DATE] and passed away on 08/26/11. [DIAGNOSES REDACTED]. Further review of CR #118's medical record revealed that on 08/20/11, the resident began having left ankle swelling. The physician was notified and the resident was started on an antibiotic for [MEDICAL CONDITION] of the left ankle. The medical record documented the resident continued on the antibiotics related to signs and symptoms of [MEDICAL CONDITION] of the left ankle through 08/23/11. On 08/23/11, CR #118 went to an orthopedic physician related to right knee issues. On 08/23/11, CR #118 returned from the orthopedic physician with a [DIAGNOSES REDACTED]. Review of the orthopedic physician progress notes [REDACTED]. The progress note documented the resident was unable to recall exactly how he hurt his ankle. There was no documentation in the resident's medical record that documented how the fracture had occurred or any documentation that anyone had witnessed the incident. On 08/26/11, CR #118 passed away of an unrelated issue. On 10/12/11 at 2:30 P.M., interview with the Director of Nursing (DON) verified CR #118 started having signs/symptoms of left lower leg [MEDICAL CONDITION] on 08/20/11 and was started on an antibiotic on 08/23/11. She stated the resident went to an orthopedic physician for an unrelated issue and returned to the facility with the left ankle fracture. The DON stated that when the resident returned from the orthopedic physician appointment, his wife stated the fracture in the ankle could be "pathological" in nature; however, the DON was unable to provide any documentation that the left ankle fracture was pathological. The DON further verified CR #118's left ankle fracture fit the definition of an injury of unknown origin as the injury could not be explained and it was not witnessed and that the injury was suspicious because of the extent since it was a fracture. She indicated she conducted an investigation of CR #118's injury and stated she should have reported the injury to ODH as required. On 10/13/11, the facility's self report incidents (SRI's) were reviewed with the DON. The review verified that CR #118's left ankle fracture of unknown origin had not been reported to ODH. Review of the facility policy entitled "Abuse, Neglect, Injuries of Unknown Source and/or Misappropriation of Resident Property" dated 10/2003, defined an injury of unknown source as an injury where the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incident of injuries over time. The policy further documented an initial report would be reported immediately to the Ohio Department of Health (ODH) and that a final report will be submitted to ODH after the investigation was completed, but no later than five working days after discovery of the incident.

Based on medical record review, staff interview and review of facility policy, it was determined the facility failed to follow their abuse policy and procedure regarding the reporting of an injury of unknown origin to the Ohio Department of Health. This affected one (#118) of one resident reviewed for injuries of unknown origin. The facility identified only one resident with an injury of unknown origin in the past three months. The facility census was 98. Findings include: Review of Closed Resident (CR) #118's medical record revealed the resident was admitted to the facility on [DATE] and passed away on 08/26/11. [DIAGNOSES REDACTED]. Further review of CR #118's medical record revealed that on 08/20/11, the resident began having left ankle swelling. The physician was notified and the resident was started on an antibiotic for [MEDICAL CONDITION] of the left ankle. The medical record documented the resident continued on the antibiotics related to signs and symptoms of [MEDICAL CONDITION] of the left ankle through 08/23/11. On 08/23/11, CR #118 went to an orthopedic physician related to right knee issues. On 08/23/11, CR #118 returned from the orthopedic physician with a [DIAGNOSES REDACTED]. Review of the orthopedic physician progress notes [REDACTED]. The progress note documented the resident was unable to recall exactly how he hurt his ankle. There was no documentation in the resident's medical record that documented how the fracture had occurred or any documentation that anyone had witnessed the incident. On 08/26/11, CR #118 passed away of an unrelated issue. On 10/12/11 at 2:30 P.M., interview with the Director of Nursing (DON) verified CR #118 started having signs/symptoms of left lower leg [MEDICAL CONDITION] on 08/20/11 and was started on an antibiotic on 08/23/11. She stated the resident went to an orthopedic physician for an unrelated issue and returned to the facility with the left ankle fracture. The DON stated that when the resident returned from the orthopedic physician appointment, his wife stated the fracture in the ankle could be "pathological" in nature; however, the DON was unable to provide any documentation that the left ankle fracture was pathological. The DON further verified CR #118's left ankle fracture fit the definition of an injury of unknown origin as the injury could not be explained and it was not witnessed and that the injury was suspicious because of the extent since it was a fracture. She indicated she conducted an investigation of CR #118's injury and stated she should have reported the injury to ODH as required. On 10/13/11, the facility's self report incidents (SRI's) were reviewed with the DON. The review verified that CR #118's left ankle fracture of unknown origin had not been reported to ODH. Review of the facility policy entitled "Abuse, Neglect, Injuries of Unknown Source and/or Misappropriation of Resident Property" dated 10/2003, defined an injury of unknown source as an injury where the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incident of injuries over time. The policy further documented an initial report would be reported immediately to the Ohio Department of Health (ODH) and that a final report will be submitted to ODH after the investigation was completed, but no later than five working days after discovery of the incident.

Based on medical record review and staff interview, it was determined the facility failed to comprehensively assess residents for the use of anti-anxiety medications (Klonopin and [MEDICATION NAME]). This affected three (#21, #45, #76) of four residents reviewed for the use of anti-anxiety (benzodiazepine) medications. The facility identified 35 residents who receive anti-anxiety medications. Findings include: 1. Review of Resident #45's medical record revealed the resident was originally admitted to the facility on [DATE] with a readmission date of [DATE]. [DIAGNOSES REDACTED]. Further review of the medical record revealed the resident had an order for [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The comprehensive admission minimum data set (MDS) assessment dated [DATE] was reviewed. The review revealed the use of the anti- anxiety (Klonopin) medication was not marked on the MDS assessment. In addition, the care area assessment (CAA) for [MEDICAL CONDITION] drug use did not trigger on the MDS. The facility also failed to code the use of the anti-anxiety medication on the following MDS assessments; the quarterly MDS dated [DATE] and the significant change MDS dated [DATE]. On 10/13/11 at 11:45 A.M., an interview with the Director of Nursing (DON) verified Resident #45 has an order for [REDACTED]. The DON further verified the use of the anti-anxiety medication was not accurately coded on Resident #45's admission MDS assessment or any MDS assessments; therefore, the CAA did not trigger for [MEDICAL CONDITION] drug usage. 2. Review of Resident #76's medical record revealed the resident was originally admitted to the facility on [DATE], with a readmission date of [DATE]. Current [DIAGNOSES REDACTED]. physician's orders [REDACTED]. The annual MDS assessment dated [DATE] does not include the use of any anti-anxiety medications during the assessment reference period. Therefore, the CAA (Care Area Assessment) for [MEDICAL CONDITION] drug use did not identify the resident to be utilizing lonazepam. Subsequent MDS assessments, including a quarterly dated 07/29/11, did not identify the resident was receiving an anti-anxiety medication during any of the assessment reference periods. A review of the June 2011 and August 2011 medication administration records verified the resident had received the [MEDICATION NAME] during the assessment reference period of 06/07/11 and 07/29/11. An interview on 10/13/11 at 11:30 A.M. with Case Manager #3 verified the use of the [MEDICATION NAME] for Resident #76 was not identified on the annual MDS of 06/07/11, or any subsequent MDS assessments. An interview on 10/13/11 at 11:45 A.M. with the Corporate Compliance Nurse revealed the facility computer system will automatically check the anti-anxiety use question at Section N of the MDS assessment based on the classification of each medication listed in the physician's orders [REDACTED]. The MDS coordinator does have the ability to override this in the MDS program and manually code Section N. 3. Review of Resident #21's medical record revealed an admission date of [DATE]. Current [DIAGNOSES REDACTED]. A review of the current physician's orders [REDACTED]. The annual MDS assessment dated [DATE] did not identify the resident had received any anti-anxiety medications during the assessment reference period. Therefore, the CAA (Care Area Assessment) for [MEDICAL CONDITION] drug use did not identify the resident was receiving any anti-anxiety medications. Additionally, the quarterly MDS assessment of 07/13/11 did not identify the resident to have received any anti-anxiety medications during the assessment reference period. An interview on 10/13/11 at 11:30 A.M. with Case Manager #3 verified the annual MDS assessment of 12/20/10 and the quarterly MDS assessment of 07/13/11 did not identify the use of the [MEDICATION NAME] as an anti-anxiety medication in Section N.