Every finding on record at Vancrest Health Care Center of Eaton

Based on record review, staff interview and policy review, the facility failed to follow physician's orders related to daily weights. This affected one (#65) out of three residents reviewed for following physician's orders. The facility census was 71. Findings include: Review of Resident #65 medical record revealed an admission date of 11/21/23 with diagnoses of acute on chronic systolic congestive heart failure, type two diabetes mellitus with diabetic peripheral angiopathy, hemiplegia and hemiparesis following cerebral infarction, chronic obstructive pulmonary disease with acute exacerbation, and Parkinson's disease. Review of the Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] revealed Resident #65 was cognitively intact. Resident #65 was independent with eating, required supervision assistance with oral hygiene, personal hygiene, and wheelchair mobility. Resident #65 required partial assistance with toileting hygiene and bed mobility, required substantial assistance with bathing and dressing, and was dependent on staff assistance with transfers. Review of Resident #65 physician orders revealed an order dated 06/09/25 for daily weights every day shift and to notify the physician if resident gains two (2) pounds in a day or five (5) pounds in a week. Review of Resident #65 weight log revealed on 06/13/26 there was no weight documented. On 06/19/26 resident weighed 321.6 pounds (Lbs.). On 06/20/26 resident weighed 324.0 Lbs. and there was no documentation of the physician being notified of the weight gain. On 06/21/26 resident weighed 326.8 Lbs. and there was no documentation of the physician being notified of the weight gain. On 06/22/26 resident weighed 327.0 Lbs. with no documentation of the physician being notified of the weight gain. On 07/03/26 there was no documentation of a weight being completed and there was no documentation of the physician being notified. On 07/13/26 resident weight weighed 324.3 Lbs. On 07/14/26 there was no documentation of a weight being completed and there was no documentation of the physician being notified. On 07/15/26 resident weighed 328.0 Lbs. with no documentation of the physician being notified of the weight gain. On 07/24/26 resident weighed 329.4. On 07/25/26 there was no documentation of a weight being completed and there was no documentation of the physician being notified. On 07/26/26 Resident weighed 333.6 Lbs. with no documentation of the physician being notified of the weight gain. Review of the progress notes for 06/13/26, 06/20/26, 06/21/26, 06/22/26, 07/03/26, 07/14/26, 07/15/26, 07/25/26 and 07/26/26 revealed no documentation of the physician being notified of weight gain and/or of no weights being obtained. Interview on 08/28/26 at 10:19 A.M. with Licensed Practical Nurse (LPN) #240 confirmed Resident #65 has a physician order for daily weights on day shift and to notify the physician if resident gains two (2) pounds in a day or five (5) pounds in a week. Interview on 08/28/26 at 3:08 P.M. with the Director of Nursing (DON) confirmed Resident #65 had a weight gain of more than two pounds in a day and/or was not weighed on 06/13/26, 06/20/26, 06/21/26, 06/22/26, 07/03/26, 07/14/26, 07/15/26, and 07/26/26. Interview with the DON also confirmed there was no documentation of the physician being notified of Resident #65's weight gain or the missed weights. Review of the Medications and Treatment Orders policy, dated July 2016 revealed the facility will follow orders consistently. This deficiency represents non-compliance investigated under Complaint Number 3034114.

Based on observation, staff interview, and review of the facility policy, the facility failed to store food in a sanitary manner. This had the potential to affect all residents receiving meals from the facility kitchen. The facility census was 69 residents. Findings include: Observation on 02/23/26 at 10:10 A.M. of the walk-in freezer revealed it contained the following: a bag of ham in a zip lock bag with an expiration date of 05/29/24, two loaves of rye bread without expiration dates, a bag of opened and undated French fries. Observation on 02/23/26 at 10:20 A.M. of the reach in refrigerator revealed it contained a box of waffles opened and undated and a bag ravioli that was opened, undated, and had an expiration date of 08/03/25. Interview on 02/23/26 at 10:25 A.M. with Facility [NAME] (FC) # 202 verified the items in the walk-in freezer and the reach-in refrigerator should have been dated upon opening and discarded when expired. Review of the facility policy titled Storage of Staples dated January 2022 revealed frozen foods should not be stored in a frozen state for more than six months, and all staples should be dated upon delivery indicating the date product was received in the facility.

Based on review of facility documents and staff interview, the facility failed to conduct a complete assessment of the facility's risk for tuberculosis (TB.) This had the potential to affect all of the residents residing in the facility. The facility census was 69 residents.Findings include: Review of the facility's TB risk assessment worksheet revealed it was undated and unsigned, and many portions of the form were not completed. The following areas were not addressed: indication of the risk level for TB (low, moderate, or ongoing transmission), number of beds in the facility, indication if there was a high incidence of immunocompromised patients or healthcare workers in the facility. Interview on 02/25/26 at 11:40 A.M. with Registered Nurse (RN) #257, the designated Infection Preventionist (IP) for the facility, the Administrator, and the Director of Nursing (DON) confirmed the facility was a low-risk setting and had no current or recent cases of TB. RN #257 stated when she assumed the IP role she did not complete the TB risk assessment form in its entirety. Review of the facility policy titled Tuberculosis Policy and Procedure undated, revealed the tuberculosis risk assessment form should be completed yearly and reviewed by the DON or designee, the Administrator, and the Medical Director.

Based on record review and staff interview, the facility failed to equitably credit interest earned from the shared resident trust account to individual resident trust accounts. This affected four (Residents #8, #39, #46 and #51) of 42 residents who had accounts with the facility. The facility census was 69 residents.Findings include: Review of resident trust account statements for Residents #8, #39, #46 and #51 revealed interest was added to the accounts randomly and was not calculated based on the balance of funds in the accounts. Interview on 02/26/26 at 3:07 P.M. with Social Services Director (SSD) #253 and Assisted Living Director (ALD) #227 confirmed the facility did not add interest to individual resident accounts based on the balance of funds in the account. Interest was awarded to accounts monthly by alphabetical lists. SSD #253 confirmed they broke up the accounts managed by the facility into fourths and rotated through each list quarterly applying interest. SSD #253 and ALD #227 confirmed there were no calculations made of account balances and interest was awarded based solely on the alphabetical lists. SSD #253 and ALD #227 confirmed interest was not awarded equitably. Interview on 02/26/26 at 3:07 P.M. with the Administrator confirmed the facility had not allocated interest to the individual resident trust fund accounts in an equitable manner, and interest should be calculated based on the balance of the individual resident account.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure medications were secure. This affected one (Resident #40) and had the potential to affect three residents identified by the facility as being cognitively impaired and independently mobile. The facility census was 69 residents. Findings include:Review of the medical record of Resident #40 revealed an admission date of 01/06/26 with diagnoses including type two diabetes mellitus, spinal stenosis, anxiety disorder, and overactive bladder. Observation on 02/23/26 at 3:20 P.M. revealed Registered Nurse (RN) #262 entered Resident #40's room with a medication cup with various medications and a small tub of vanilla pudding. RN #262 placed the items on the overbed table and walked out of the room, closing the door behind her. Resident #40 began to take the medications, using pudding. RN #262 then returned to the room with a glass of water. Interview on 02/23/26 at 3:21 P.M. with RN #262 confirmed she had left the medications unattended on Resident #40's overbed table. Review of the facility policy titled Storage of Medications undated revealed drugs should be stored in a safe, secure, and orderly manner. This deficiency represents noncompliance investigated under Complaint Number 2668753.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to perform proper incontinence care. This affected one (Resident #69) of one resident reviewed for incontinence care. The facility census was 69 residents. Findings include:Review of the medical record for Resident #69 revealed an admission date of 12/15/25 with diagnoses including end stage renal disease, chronic combined congestive heart failure, and hemiplegia and hemiparesis following a stroke. Review of the Minimum Data Set (MDS) assessment for Resident #69 dated 12/22/25 revealed the resident was cognitively impaired, was dependent on staff for toileting, and had an indwelling urinary catheter. Observation on 02/26/26 at 10:20 A.M. of catheter care for Resident #69 per Certified Nursing Assistants (CNAs) #269 and #285 revealed the aides removed the incontinent brief and used a disposable wipe to cleanse the resident's peri area separating the labia and wiping from the front to back. CNA #269 then arranged the wipe to a different section before wiping again. Observation revealed the wipe had brown colored material present after cleansing the urethral area. CNA #269 disposed of the wipe and pulled a clean wipe from the package. CNAs #269 and #285 completed perineal care to the resident's anterior side, reapplied the same incontinent brief and exited the room. Interview on 02/26/26 at 10:40 A.M. with CNAs #269 and #285 verified the disposable wipe used for peri care for Resident #69 had brown material visible on the wipe after the first stroke during perineal care. The CNAs confirmed they did not provide any further perineal care to ensure the resident's posterior area was clean and free of irritation. Interview on 02/26/26 at 10:52 A.M. with Registered Nurse (RN) #257 verified the CNAs should have provided thorough and complete incontinent care to Resident #69. Review of the facility policy titled Incontinent Care undated revealed resident's skin should be kept clean, dry and free of irritation and odor.

Based on medical record review, observation, staff interview, and resident interview, the facility failed to ensure only licensed staff administered oxygen to residents and that oxygen tubing was handled in a sanitary manner. This affected one (Resident #49) of 14 facility-identified residents receiving oxygen. The facility failed also failed to ensure oxygen tubing was dated. This affected two (Residents#13 and #22) of 14 facility-identified residents receiving oxygen. The facility census was 69 residents. Findings include: 1.Review of the medical record of Resident #49 revealed an admission date of 10/23/25 with diagnoses include acute and chronic respiratory failure, pulmonary fibrosis, and interstitial lung disease. Review of the physician's orders for Resident #49 revealed an order dated 10/31/25 for continuous oxygen at three liters per minute via nasal cannula. Review of the Minimum Data Set (MDS) assessment for Resident #49 dated 12/28/25 revealed the resident cognitively impaired and received oxygen. Observation on 02/23/26 at 11:59 A.M. revealed Resident #49 was seated in his wheelchair in the dining room, at a table with three other males. Certified Nursing Assistant (CNA) #321 disconnected the nasal cannula tubing from the portable oxygen tank and tucked it behind Resident #49. CNA #321 removed the tank from the holder on the wheelchair and walked with it to an oxygen storage room and placed the tank in a holder. Resident #49's oxygen tubing had fallen to the floor. Approximately three minutes later, Licensed Practical Nurse (LPN) #243 brought a new tank to Resident #49 and attached the tubing from off the floor to the new tank. Interview on 02/23/26 at 12:03 P.M. with LPN #243 confirmed she had attached the tubing which had been lying on the floor to the new tank for Resident #49. Interview on 02/23/26 at 12:07 P.M. with CNA #321 confirmed she had removed Resident #49's oxygen. 2. Review of the medical record for Resident #22 revealed an admission date of 12/26/24 with diagnoses including malignant neoplasm of the right lung and congestive heart failure. Review of the MDS for Resident #22 dated 01/01/26 revealed the resident was cognitively intact and had shortness of breath when lying flat. Review of the physician's orders for Resident #22 dated February 2026 revealed and order for oxygen at two liters per minute at night. Interview on 02/23/26 at 2:02 P.M. with Resident #22 confirmed she experienced shortness of breath at night and she used oxygen at two liters at bedtime. Observation on 02/25/26 at 8:17 A.M. revealed the oxygen tubing for Resident #22 was undated. Interview on 02/25/26 at 8:18 A.M. with LPN #286 confirmed Resident #22's oxygen tubing was not dated and confirmed it should have been dated upon application. 3. Review of the medical record for Resident #13 revealed an admission date of 07/10/25 with diagnoses including end stage renal disease, diabetes, and atrial fibrillation. Observation on 02/25/26 at 2:57 P.M of Resident #13 revealed the resident was receiving oxygen via oxygen concentrator, and the oxygen tubing was undated. Interview on 02/25/26 at 2:57 P.M. with LPN #286 confirmed Resident #13's oxygen tubing was undated and confirmed oxygen tubing should have been dated upon application

Based on medical record review, review of hospice visit logs, facility staff interview, hospice staff interview, and review of hospice contracts, the facility failed to ensure hospice documentation was sufficient and available for review by facility staff to ensure assessments, treatments and care planning were provided per plan of care. Additionally, the facility failed to jointly collaborate with hospice to develop resident care plans. This affected two (Residents #23 and #58) of two residents reviewed for hospice services. The census was 69 residents.Findings include: 1.Review of the medical record for Resident #58 revealed an admission on [DATE] with diagnoses including non-Hodgkin's lymphoma and heart failure. Review of the Minimum Data Set (MDS) assessment for Resident #58 dated 01/31/26 for the resident revealed the resident had impaired cognition, was dependent on staff for activities of daily living (ADLs), and received hospice services. Review of the hospice plan of care for Resident #58 dated 12/13/25 revealed hospice staff visits included a nurse visit one to two times a week for nine weeks and as needed visits for symptom management, a hospice aide visit three times a week for nine weeks, and a chaplain visit one to two times for two months with as needed visits for spiritual support. Review of the hospice agency binder at the facility nurses station revealed the binder contained dates of hospice aide visits for Resident #58 dated 04/22/25, 04/25/25, 04/29/25, 05/02/25, 05/06/25, 05/09/25, 05/13/25, 05/16/25, 05/20/25, 05/23/25, 05/27/25, 07/18/25, 08/15/25, 01/20/26, 02/20/26, and 02/24/26. The binder did not include documentation of the services provided by aide. Interview on 02/26/26 at 1:40 P.M. with Registered Nurse (RN) #257 confirmed the facility did not have any charting for bathing or shampooing for Resident #58 as this was completed by the hospice aide. RN #257 verified the hospice binder gave dates when the hospice aide was present at the facility but did not include documentation of care provided. Interview on 02/26/2026 at 2:20 P.M. with Director of Nursing (DON) verified the facility staff does not have access to the hospice medical record or visit notes from the hospice providers. DON stated if the facility needs any information related to the hospice care of Resident #58 they have to call the hospice agency. Interview on 02/26/26 at 3:48 P.M. with Hospice Registered Nurse (RN) #400 verified she did not develop Resident #58's hospice care plan in collaboration with the facility staff and did not review the facility care plan to ensure services provided by the hospice agency were identified. RN #400 stated she has not provided documentation to the facility regarding visits, assessments or treatments completed on a routine basis for Resident #58. 2.Review of the medical record for Resident #23 revealed an admission date of 11/01/24 with diagnoses including dementia, atherosclerotic heart disease, and congestive heart failure (CHF). Review of the physician's orders for Resident #23 revealed an order dated 11/01/24 to admit the resident to hospice. Review of the hospice care plan dated for Resident #23 dated 01/28/26 revealed the resident was admitted to hospice on 12/13/24 with a primary diagnosis of CHF. Hospice staff visits included a nurse visit one to two times per week for nine weeks and as needed for symptom management, a hospice aide visit twice a week for nine weeks, a chaplain visit one to two times per month for two months and as needed for spiritual support, and a social worker visit one to two times per month for two months and as needed for emotional support. Review of the hospice visitation binder for Resident #23 dated 05/16/25 to 02/26/26 revealed the following visits were recorded: 12 hospice aide visits, two nurse visits, one chaplain visit. Interview on 02/26/26 at 9:00 A.M. with RN #254 confirmed the facility had a log of visits by hospice staff for Resident #23 but did not have documentation regarding the services provided. Interview on 02/26/2026 9:39 A.M. with Hospice RN #400 confirmed hospice staff documented on their mobile devices and the facility did not have access to these notes. RN #400 confirmed the facility could call hospice if they needed information on Resident #23. Review of the nursing home hospice care agreement dated 10/01/19 revealed the hospice and the facility would jointly develop and agree upon a care plan which was consistent with the hospice philosophy and was responsive to the needs of the residents. It was the responsibility of the hospice agency to provide the facility with sufficient information to ensure services were being provided per the care plan.

Based on medical record review, observations, staff interview, review of facility policy and review of Centers for Disease and Prevention (CDC) guidelines, the facility failed to ensure infection control procedures were followed during incontinence care. This affected one (#11) out of three residents reviewed for incontinence care. The facility census was 71. Findings include: Review of medical record for Resident #11 revealed admitted [DATE]. Diagnoses include dementia without behavior and type two diabetes mellitus. Review of Resident #11's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 11 indicating impaired cognition. Resident #11 required moderate assistance with toileting hygiene, was independent with eating moderate assistance for transfers, supervision for bed mobility. Resident #11 was always in urine and bowel. Observation of incontinence care for Resident #11 on 01/07/25 at 9:37 A.M. revealed Certified Nursing Assistant (CNA) #104 used gloves hands to cleanse Resident #11's peri area. CNA #104 then requested Resident #11 to turn onto her right side. CNA #104 then removed the wet incontinence product, disposed of it in the trash can beside the bed and then cleansed Resident #11's buttocks. After tucking a new incontinence product, she requested Resident #11 to roll over and onto her left side in order to position the incontinence product properly underneath her. The new product was secured by CNA #104 and Resident #11's gown was readjusted and was recovered in blankets. CNA #104 removed the trash liner from the can, tied it off and walked into the hallway. At no time did CNA #104 remove her gloves. Interview on 01/07/25 at 9:54 A.M. with CNA #104 verified she had not removed her gloves after providing incontinence care and exiting Resident #11's room. Record review of the undated facility policy, Incontinence Care documented to remove gloves and place in plastic liner, tie plastic liner, wash hands and dispose of the liner. Review of the CDC guidelines at https://www.cdc.gov/clean-hands/hcp/clinical-safety documented staff should remove gloves before exiting a resident room. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure as needed (PRN) antipsychotic medications prescribed were limited to 14 days. Additionally, the facility failed to re-evaluate a resident for continued use of PRN antipsychotic medication. This affected one (Resident #14) of five residents reviewed for psychotropic medications. Additionally, the facility failed to ensure pharmacy recommendations were addressed by the physician in a timely manner. This affected one (Resident #15) of five residents reviewed for pharmacy recommendation response. The facility's census was 49. Findings include: 1. Medical record review for Resident #14 revealed an admitted [DATE]. Resident #14 was discharged on [DATE] and returned on 09/06/22 with diagnoses including but not limited to respiratory failure, interstitial pulmonary disease, pulmonary fibrosis, peripheral vascular disease, paroxysmal fibrillation, chronic diastolic congestive heart failure, hypotension, polyneuropathy, anxiety, shortness of breath, right bundle block, and diaphragmatic hernia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact and required extensive assistance with Activities of Daily Living (ADLs). Resident #14 received antianxiety and antidepressant medications during the assessment period. Review of the plan of care dated 09/12/22 and revised on 10/03/22 revealed Resident #14 was at risk for altered mood pattern related to generalized anxiety disorder. Interventions included administer medications as ordered, explain the importance of taking medication, monitor for signs and symptoms of anxiety, one on one visits as needed, and review medications as needed for recommendations for gradual trial reduction. Review of the hospital discharge orders dated 09/06/22 revealed an order for Ativan (medication used to treat anxiety) 1 milligram (mg) every 12 hours as needed for four days. Review of the physician progress note dated 09/09/22 revealed no documentation the physician re-assessed the resident for the appropriateness Ativan administration. Review of the physician order dated 09/16/22 revealed an order for Ativan 1 mg tablet, give one tablet every twelve hours as needed (PRN) for anxiety, dispense 60 tablets. Further review of the handwritten prescription revealed no stop date was identified. Review of the physician progress note dated 09/30/22 revealed no documentation related to continued use of Ativan. Review of Resident #14's Medication Administration Record (MAR) for September 2022 revealed an order for Ativan 1 mg tablet, give one tablet by mouth as needed for congestive heart failure dated 09/06/22 and discontinued on 10/12/22. Further review of the MAR revealed Ativan was administered on 09/07/22, 09/16/22, 09/17/22, 09/18/22, 09/19/22, 09/20/22, 09/21/22, 09/22/22, 09/23/22, 09/25/22, 09/26/22, 09/27/22, 09/29/22, and 09/30/22. Review of Resident #14's MAR for October 2022 revealed an order for Ativan 1 mg, give one tablet by mouth every 12 hours as needed for congestive heart failure dated 09/06/22 and discontinued on 10/12/22. Ativan was administered on 10/01/22, 10/02/22, 10/03/22, 10/04/22, 10/09/22, and 10/10/22. Additional review revealed an order for Ativan 1 mg one tablet by mouth as needed for congestive heart failure dated 10/12/22 and discontinued 10/20/22. Ativan 1 mg by mouth was administered on 10/13/22, 10/14/22, 10/17/22. Further review revealed an order for Ativan 1 mg tablet, give one tablet by mouth every 12 hours as needed for anxiety dated 10/20/22. Ativan 1 mg by mouth was administer on 10/20/22 and 10/21/22. Review of the physician progress note dated 10/29/22 revealed no documentation the physician re-assessed the resident for the appropriateness Ativan administration or justified reasoning for continued Ativan use. Review of physician orders revealed an order for Ativan 1 mg, give one tablet by mouth two times a day for anxiety dated 12/06/22 and discontinued on 12/28/22. An order for Ativan 1 mg tablet, give one by mouth every 12 hours as needed for anxiety dated 12/28/22. Review of Resident #14's MAR for December 2022 revealed an order for Ativan 1 mg, one tablet by mouth two times a day for anxiety dated 12/06/22 and discontinued on 12/28/22. Resident #14 received Ativan two times a day from 12/06/22 through 12/28/22. Further review of the medical record revealed no documentation PRN Ativan was limited to 14 days. Additional review revealed no documentation the physician re-assessed the resident for the appropriateness of Ativan administration nor was there any documentation alleging the resident required long term use of Ativan. Interview on 01/11/23 at 10:39 A.M. with Licensed Practical Nurse (LPN) #119 verified the order for Ativan dated 09/16/22 was a PRN order and did not have a stop date limiting use to 14 days. Interview on 01/11/23 at 2:10 P.M. with Consulting Pharmacist #69 verified there were no recommendations made for the PRN Ativan in September 2022. Interview on 01/11/23 at 2:19 P.M. with the Director of Nursing (DON) verified the physician progress notes did not contain documentation related to Resident #14 being reassessed for the appropriateness of PRN or continued use for Ativan. Review of the facility policy titled, Antipsychotic Medication Use, dated 12/2016 revealed residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medication, will be evaluated for the appropriateness and indications for use. The facility will re-evaluate the use of antipsychotic medication at the time of the admission or within two weeks to consider whether of not the medication can be reduced, tapered or discontinued. 30802 2. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, dementia with severe anxiety, chronic respiratory failure with hypoxia, psychosis, major depressive disorder, generalized anxiety disorder, and insomnia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #15 was severely cognitively impaired and required extensive assistance or was totally dependent upon staff for ADLs. Resident #15 received an antipsychotic, antianxiety, antidepressant, a diuretic, and an opioid medication seven times in the seven day look back period. Review of the care plan revealed Resident #15 had the potential for or actual decline in condition related to receiving hospice services, adjustment disorder, depression, grief, and anxiety. Review of a pharmacy recommendation dated 02/23/22 regarding Resident #15's order for Lorazepam (medication used to treat anxiety) 1 mg via peg tube every four hours as needed (PRN) for agitation/anxiety revealed a recommendation that if the physician felt it was appropriate for the PRN order to be extended beyond 14 days, the physician should document rationale and indicate the duration of the PRN order. Further review of the medical record revealed the physician did not address the pharmacy recommendation until 05/02/22. Interview on 01/12/23 at approximately 1:30 P.M. with the Director of Nursing (DON) verified the physician did not address the pharmacy recommendation dated 02/23/22 until 05/02/22. The DON indicated the expectation was for the physician to address the pharmacy recommendation sooner.

Based on observations, staff interview, and review of facility policy, the facility failed to ensure medication carts were secured when unattended. This had the potential to affect four (Residents #4, #12, #26, and #42) identified by the facility as confused and independently mobile residing on the South unit. The facility census was 49. Findings included: Observation on 01/09/23 at 12:20 P.M. revealed the medication cart located on the South unit was unlocked and unattended. Licensed Practical Nurse (LPN) #119 was in a resident's room. Interview on 01/09/23 at 12:30 P.M. with LPN #119 verified the medication cart was unlocked and unattended while she was in a resident's room. 39702 Observation on 01/11/23 at 11:21 A.M. revealed the medication cart located on the South unit was unlocked and unattended. Interview on 01/11/23 at 11:29 A.M. with Licensed Practical Nurse (LPN) #119 verified the medication cart was unlocked and unattended in the unit hallway LPN #119 verified the medication cart should be locked when unattended. Review of the facility policy titled Storage of Medication dated 04/2007 revealed compartments containing drugs and biologicals shall be locked when not in use and shall not be left unattended and otherwise potentially available to others.

Based on medical record review, staff interview, and facility procedure review, the facility failed to complete laboratory tests in a timely manner. This affected one (Resident #58) of three residents reviewed for physician orders. The census was 56. Findings Include: Review of the medical record for Resident #58 revealed Resident #58 was admitted to the facility on [DATE]. Resident #58's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #58's Minimum Data Set assessment, dated 03/12/22, revealed she was cognitively intact. Review of Resident #58's medical records revealed she had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #58's urinalysis was not collected and sent to the laboratory until 03/08/22. After the specimen was collected and analyzed by the lab, it was determined Resident #58 had minimal and trace amounts of bacteria and infection. The facility notified the physician about Resident #58's lab results on 03/08/22 and the physician ordered [MEDICATION(S)] 800-160 mg twice daily for the urinary tract infection. Further review of Resident #58's medical record revealed there was no documentation to support why the delay occurred. Resident #58 did not have any care plan or documentation to support she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Interviews with Registered Nurse (RN) #101, State tested Nurse Aide (STNA) #102, Licensed Practical Nurse (LPN) #103, LPN #104, and RN #105, on 04/15/22 at 10:15 A.M., 12:55 P.M., 1:08 P.M., 3:10 P.M., and 3:24 P.M., confirmed the laboratory was in the facility on Mondays, Wednesdays, and Fridays. They confirmed on the days the lab is scheduled to be on site, they are to collect specimens and ensure they are sent to the lab for timely analysis. They confirmed if the lab is not a stat order, they can wait for a Monday, Wednesday, or Friday to have the lab collected. But if a lab is ordered stat, they are to contact the lab immediately for collection or contact a local hospital to get the lab completed. Stat labs are to be completed when there is a change in resident's condition; it doesn't have to be significant. Interview with the Director of Nursing (DON) and Administrator on 04/15/22 at 9:55 A.M., 11:15 A.M., 3:35 P.M., 3:54 P.M., and 4:10 P.M., confirmed Resident #58 had a lab order for a urinalysis, which was dated for Friday 03/04/22. The DON and Administrator did not know why the order/specimen was not collected until 03/08/22. They confirmed the original order was given on a Friday, which was when the laboratory was already scheduled to be in the facility. They confirmed the specimen was also not collected on 03/07/22, which was a Monday and was another scheduled day for the lab to be in the facility. They confirmed there was no documentation within Resident #58 medical records to provide an explanation or justification as to why the urinalysis was not collected as ordered on 03/04/22. They also confirmed the physician ordered [MEDICATION(S)] to treat the urinary tract infection after the results came back on 03/08/22. Review of facility procedures for Specimen Collections, undated, revealed routine and non-emergency labs are picked up and/or collected on Mondays, Wednesdays, and Fridays. If lab work is needed on weekends or Tuesdays/Thursdays (stat orders), nursing staff from the facility will call the lab and schedule the collection. This deficiency substantiates Complaint Number OH 562.

Based on medical record review, resident interview, and staff interview, the facility failed to ensure residents were provided assistance with bathing. This affected two (#28 and #52) of three residents reviewed for showers. The facility census was 54. Findings include: Review of the medical record of the Resident #52 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent on two staff for bathing. Interview on 02/04/22 at 11:47 A.M., with Resident #52 revealed he received 2 showers this week, however , he went 14 days a few weeks ago without having a shower. Review of shower/bathing task documentation for 01/01/22 to 01/29/22 revealed Resident #52 received a shower on 01/04/22 and 01/11/22. No additional showers or bed baths were documented during the specified time frame. 2. Review of the medical record of Resident #28 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive MDS assessment dated [DATE] revealed the resident had intact cognition. The resident required extensive assistance of one person for personal hygiene and was not bathed during the assessment period. Review of shower/bathing task documentation dated 1/20/22 through 02/04/22 revealed the resident received a shower on 01/25/22. No additional showers or bed baths were documented during the specified time frame. Interview on 02/04/22 at 3:40 P.M., Resident #28 stated it had been a few weeks since he last received a shower. Resident #28 stated he knew for sure he had not received a shower this week and stated he wasn't sure if he'd received one the week prior. Resident #28 further stated he heard someone say the facility just isn't giving them. Interview on 02/04/22 at 4:47 P.M., with the Director of Nursing (DON) revealed residents should be offered showers twice per week. The DON further verified a lack of documentation for Resident #28 receiving a shower since 01/25/22 and Resident #52 receiving a shower from 01/12/22 through 01/29/22. This deficiency substantiates Complaint Number OH 499.

Based on medical record review and staff interview, the facility failed to ensure physician's orders to keep surgical dressing in place were followed upon a residents admission. This affected one (#150) of three residents reviewed. The facility census was 49. Findings included: Review of medical record for Resident #150 revealed an admission on 10/08/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] for Resident #150 revealed an intact cognition. Resident #150 required extensive assist for bed mobility, transfers, and toileting from two staff members. Resident #150 was coded as having a surgical incision and requiring surgical wound care. Review of the plan of care for Resident #150 revealed the resident had the potential for or impairment of skin related to surgical site on right knee. Interventions included administer medications as ordered, laboratory tests as ordered, monitor vital signs as needed, assess skin daily for signs and symptoms of infection, monitor for pain and medicate as ordered, report any abnormalities as needed and treatment as ordered. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Change as needed for saturation. Review of completed physician's orders for Resident #150 revealed an order dated 10/08/21 to keep dressing to right knee clean, dry, and intact for forty-eight hours. Change as needed for saturation. Review of the hospital discharge instructions for Resident #150 dated 10/08/21 revealed orders to keep dressing clean, dry, and intact for 48 hours. Review of the admission nursing assessment for Resident #150 dated 10/08/21 revealed the area to the right knee measured 23 centimeters (cm) long and one cm wide. Further revealed under the comment section of skin integrity that Resident #150 had 45 staples to right knee at the time of admission. Interview on 12/20/21 at 3:30 P.M. with Registered Nurse (RN) #25 verified Resident #150's dressing to the right knee was removed to count the staples and to measure the surgical incision and it should not have been. Interview on 12/27/21 at 7:50 A.M. with admitting RN #100 verified the dressing present on Resident #150 right knee was removed to visually look at the wound and obtain measurements and it should not have been. RN #100 verified Resident #150 had a do not remove order pertaining to the dressing to the right knee from the hospital and she was not aware of the order until after the dressing was removed. This deficiency substantiates Compliant Number OH 200.

Based on closed medical record review, hospital documentation review, physical therapy progress notes, staff interview, and policy review, the facility failed to ensure a resident on antihypertensive medication was adequately monitored for hypotension. This resulted in actual harm when Resident #66 was administered antihypertensive medications while having multiple blood pressure (BP) assessments significantly below the residents baseline BP. Additionally, the facility failed to ensure the physician was notified timely of the resident's hypotensive BP assessments. This affected one (Resident #66) of one resident reviewed for hospitalization. The census was 65. Findings include: Review of the closed medical record revealed Resident #66 was admitted to the facility on [DATE]. Diagnoses included disorder involving immune mechanism, hypertension, atrial fibrillation, congestive heart failure, peripheral vascular disease, kidney transplant status, chronic kidney disease, complete atrioventricular block, left bundle branch block, and presence of a cardiac pacemaker. The resident was discharged to the hospital on [DATE]. Review of hospital documentation dated 06/26/19, prior to Resident #66's admission to the facility revealed her BP was 104/59. Review of Resident #66's BP assessments revealed on 06/26/19 the residents BP was 110/60. Further review of the BP assessments revealed the following: on 06/27/19 at 2:37 A.M., BP was 102/56, on 06/27/19 at 11:09 A.M., BP was 126/67, on 06/28/19 at 12:50 P.M., BP was 128/76, on 06/29/19 at 6:35 A.M., BP was 109/62, on 06/29/19 at 6:35 A.M., BP was 109/62, on 07/05/19 at 3:01 P.M., BP was 92/60, on 07/06/19 at 3:01 P.M., BP was 100/62, on 07/07/19 at 3:01 P.M., BP was 82/52, on 07/08/19 no time BP was 96/52, and on 07/09/19 at 2:52 P.M., BP was 80/50. Review of the medication administration record (MAR) dated 07/2019, revealed Resident #66 was administered metoprolol succinate extended release (beta blocker) tablet 50 milligrams (mg) by mouth for hypertension at 8:00 A.M. on 07/05/19, 07/06/19, 07/07/19, 07/08/19, and 07/09/19. Further review of the MAR revealed the resident was administered enalapril maleate (ace inhibitor) tablet 20 mg by mouth two times a day for hypertension on 07/05/19, 07/06/19, 07/07/19 and 07/08/19 at 8:00 A.M. and 8:00 P.M., and on 07/09/19 at 8:00 A.M. The 8:00 P.M. dose of enalapril maleate was held. On 07/09/19 at 8:00 P.M. the 20 mg of enalapril maleate was administered to Resident #66. Further review of the MAR revealed Resident #66 was administered doxazosin mesylate (alpha blocker) tablet four mg by mouth for hypertension at 8:00 P.M. on 07/05/19, 07/06/19, 07/07/19 and 07/08/19. Review of physical therapy progress notes dated 07/04/19 revealed Resident #66 experienced episodes of his BP dropping during treatment. At the beginning of therapy his BP was 87/54. The residents first standing BP was 80/55 and the second standing BP was 84/63. Documentation revealed nursing staff were notified of the residents varying BP while in therapy. Review of a physical therapy progress note dated 07/09/19 revealed Resident #66 was very lethargic and unable to participate fully with the treatment session. Documentation revealed the resident's nurse was to assess the resident's BP. Review of the nurse progress notes dated 07/04/19 revealed no evidence of nursing assessing Resident #66 or of the physician being notified of the residents varying BP during physical therapy. Review of the nurse progress notes dated 07/05/19, 07/07/19 and 07/08/19 revealed no evidence of physician notification for the low BP readings. Review of the nurse progress notes dated 07/09/19 at 3:17 P.M. revealed the residents BP was 80/50. Resident #66 was assessed with shortness of breath, cough, and increased weakness. Documentation revealed the cardiologist was notified of the residents change of condition and faxed a medication list, vital signs and recent laboratory results. Review of the nurse progress note dated 07/10/19 at 9:59 A.M. revealed new orders for antihypertensive medication adjustments were received from the cardiologist. Review of the nurse progress notes dated 07/11/19 at 5:10 P.M. revealed the resident was noted to have multiple low BP readings and medication changes had little effects. The resident complained of feeling lethargic, decreased appetite, and the inability to participate with therapy services due to symptoms. The physician was notified and a new order was obtained to send the resident to the hospital for evaluation and treatment. Review of hospital documentation dated 07/11/19 at 5:39 P.M. revealed the resident was sent to the local emergency department. Resident #66's vital signs were BP 91/57 mmHg, temperature 98.5 degrees Fahrenheit, respirations 15, and oxygen saturation 97 percent. Clinical impression included generalized weakness, hypotension,acute kidney injury, and transaminitis. Documentation revealed the resident was to be transferred to another hospital were the resident's specialist was located. Telephone interview on 10/03/19 at 8:42 A.M. with the primary care physician for Resident #66 revealed the physician could not recall if the facility called to notify of the low BP assessments. Interview on 10/03/19 at 8:57 A.M. with physical therapy assistant (PTA) #302 revealed the PTA worked with Resident #66 frequently. PTA #302 revealed Resident #66's therapy sessions were often shortened because the resident was lethargic and did not feel well. PTA #302 revealed the resident's BP would often drop during treatment sessions. The PTA reported nursing was made aware when the resident had low BP readings. The PTA had no knowledge if the doctor was made aware of the resident having BP reading concerns during therapy sessions. Interview on 10/03/19 at 9:13 A.M. with licensed practical nurse (LPN) #304 revealed residents who were skilled had their BP assessed every eight hours for the first three days, then every 72 hours while the resident was skilled, and then weekly. BP would be monitored more often if a resident had physician ordered BP medications such as an antihypertensive medication that had parameters with medication administration. LPN #304 revealed a BP reading should be reported to the physician any time the BP dropped below the residents baseline. The LPN revealed per nursing judgment, antihypertensive medication should be held and the doctor notified for further instruction anytime a residents systolic BP falls below 100, unless the resident had physician ordered BP parameters. LPN #304 revealed Resident #66 did not have orders for monitoring the resident's BP prior to the administration of antihypertensive medications. LPN #304 verified antihypertensive medication was administered to Resident #66 on 07/05/19, 07/06/19, 07/07/19, and 07/08/19. The LPN further verified Resident #66's BP was below his baseline on 07/05/19, 07/06/19, 07/07/19, and 07/08/19. LPN #304 verified the residents physician should have been notified of the low BP assessment on 07/05/19 when the residents BP was 92/60. The LPN further verified the physician should have also been notified immediately of the low BP readings on 07/06/19, 07/07/19, and 07/08/19. The LPN confirmed the medical record for Resident #66 contained no evidence of the primary care physician or the cardiologist being notified of the residents low BP readings until 07/09/19, four days after the residents initial low BP reading was obtained. Interview on 10/03/19 at 10:09 A.M. with the cardiologist revealed the facility called the cardiology office on 07/09/19 to inform them Resident #66 was experiencing low BP readings. The cardiologist's nurse returned a call to the facility on [DATE] to have Resident #66 sent to the hospital for evaluation and treatment. The cardiologist revealed after speaking with the facility on 07/10/19 it was decided not to send the resident to the hospital but rather make medication adjustments at the facility. The cardiologist revealed it would be expected that the facility would have notified the cardiologist or the primary care physician immediately of the initial low BP of 82/52 that was assessed on 07/07/19. The cardiologist verified the facility did not notify the cardiologist of Resident #66's low BP readings until 07/09/19. Review of a policy titled, Notification of Change undated, revealed the facility will consult with the resident's physician when there is a significant change in the residents physical, mental, or psychosocial status (that is deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications).

Based on medical record review, policy review, staff interview, review of center for disease control (CDC) guidance the facility failed to provide pneumonia vaccinations according to current CDC guidelines. This directly affected five Residents (#17, #19, #23, #26 and #117) of five reviewed for immunizations. This had the potential to affect any resident eligible to receive the pneumococcal vaccination series by the physician. The total facility census was 65. Findings include: 1. Review of the medical record revealed Resident #17 was admitted on [DATE] and received the PPSV23 on 10/22/15, prior to admission. 2. Review of the medical record revealed Resident #19 was admitted on [DATE] and had received a Pneumococcal [MEDICATION NAME] Vaccine (PPSV)23 vaccination on 08/09/17, prior to admission. 3. Review of the medical record revealed Resident #23 was admitted on [DATE] and had a historical Pneumococcal Conjugate Vaccine (PCV)13 vaccination on 02/20/18, prior to admission. 4. Review of the medical record revealed Resident #26 was admitted on [DATE] and received PPSV23 on 12/01/12, prior to admission. 5. Review of the medical record revealed Resident #117 was admitted on [DATE] and received PPSV23 on 02/22/17, prior to admission. During an interview with Registered Nurse (RN) #300 on 10/03/19 at 11:15 [NAME]M. it was revealed the facility offered PPSV23 only and they have not offered PCV13. RN #300 indicated the facility could not get PCV13 from their pharmacy supplier. During a follow up interview with RN #300 on 10/03/19 at 11:24 [NAME]M. it was confirmed the facility was able to obtain PCV13 from the pharmacy and could administer the vaccination to the facility residents. The RN stated she had spoken to the Director of Nursing (DON) and received clarification. The RN stated the five residents reviewed had either refused the vaccinations or came from the community already vaccinated. The five residents reviewed did not have have refusals documented and because they had one of the vaccinations. The surveyor explained to the nurse there was a sequencing of vaccinations and guidelines included administration of both vaccines to the residents. The nurse verified she had been in her position for two years and in that time the facility had not offered PCV13 to any of the residents. Review of the facility policy titled Pneumococcal Vaccine dated (MONTH) (YEAR) revealed all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current CDC recommendations at the time of the vaccination. Review of the CDC guidelines revealed Pneumococcal vaccination schedule revealed: Routine vaccination: Age [AGE] years or older (immunocompetent): One dose PCV13 if previously did not receive PCV13, followed by one dose PPSV23 at least one year after PCV13 and at least five years after last dose PPSV23. When a person previously received PPSV23 but not PCV13 at age [AGE] years or older: give one dose PCV13 at least one year after PPSV23. When both PCV13 and PPSV23 are indicated, administer PCV13 first (PCV13 and PPSV23 should not be administered during same visit) Special situations Age 19 through [AGE] years with chronic medical conditions (chronic heart (excluding hypertension), lung, or liver disease; diabetes), alcoholism, or cigarette smoking: one dose PPSV23 Age [AGE] years or older with immunocompromising conditions (congenital or acquired immunodeficiency (including B- and T-lymphocyte deficiency, complement deficiencies, phagocytic disorders,[MEDICAL CONDITION]), [MEDICAL CONDITION], nephroti[DIAGNOSES REDACTED], [MEDICAL CONDITIONS], Hodgkin disease, generalized malignancy, iatrogenic immunosuppression (e.g., drug or [MEDICAL CONDITION] therapy), solid organ transplant, [DIAGNOSES REDACTED]) or anatomical or functional asplenia (including [MEDICAL CONDITION] cell disease and other hemoglobinopathies): one dose PCV13 followed by one dose PPSV23 at least eight weeks later, then another dose PPSV23 at least five years after previous PPSV23; at age [AGE] years or older, administer one dose PPSV23 at least five years after most recent PPSV23 (note: only one dose PPSV23 recommended at age [AGE] years or older) Age [AGE] years or older with [DIAGNOSES REDACTED] or cochlear implant: one dose PCV13 followed by one dose PPSV23 at least eight weeks later; at age [AGE] years or older, administer another dose PPSV23 at least five years after PPSV23 (note: only one dose PPSV23 recommended at age [AGE] years or older).

Based on closed medical record review, hospital documentation review, physical therapy progress notes, staff interview, and policy review, the facility failed to ensure a resident on antihypertensive medication was adequately monitored for [MEDICAL CONDITION]. This resulted in actual harm when Resident #66 was administered antihypertensive medications while having multiple blood pressure (BP) assessments significantly below the residents baseline BP. Additionally, the facility failed to ensure the physician was notified timely of the resident's hypotensive BP assessments. This affected one (Resident #66) of one resident reviewed for hospitalization . The census was 65. Findings include: Review of the closed medical record revealed Resident #66 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident was discharged to the hospital on [DATE]. Review of hospital documentation dated 06/26/19, prior to Resident #66's admission to the facility revealed her BP was 104/59. Review of Resident #66's BP assessments revealed on 06/26/19 the residents BP was 110/60. Further review of the BP assessments revealed the following: on 06/27/19 at 2:37 [NAME]M., BP was 102/56, on 06/27/19 at 11:09 [NAME]M., BP was 126/67, on 06/28/19 at 12:50 P.M., BP was 128/76, on 06/29/19 at 6:35 [NAME]M., BP was 109/62, on 06/29/19 at 6:35 [NAME]M., BP was 109/62, on 07/05/19 at 3:01 P.M., BP was 92/60, on 07/06/19 at 3:01 P.M., BP was 100/62, on 07/07/19 at 3:01 P.M., BP was 82/52, on 07/08/19 no time BP was 96/52, and on 07/09/19 at 2:52 P.M., BP was 80/50. Review of the Medication Administration Record [REDACTED].M. on 07/05/19, 07/06/19, 07/07/19, 07/08/19, and 07/09/19. Further review of the MAR indicated [REDACTED].M. and 8:00 P.M., and on 07/09/19 at 8:00 [NAME]M. The 8:00 P.M. dose of [MEDICATION NAME] was held. On 07/09/19 at 8:00 P.M. the 20 mg of [MEDICATION NAME] was administered to Resident #66. Further review of the MAR indicated [REDACTED].M. on 07/05/19, 07/06/19, 07/07/19 and 07/08/19. Review of physical therapy progress notes dated 07/04/19 revealed Resident #66 experienced episodes of his BP dropping during treatment. At the beginning of therapy his BP was 87/54. The residents first standing BP was 80/55 and the second standing BP was 84/63. Documentation revealed nursing staff were notified of the residents varying BP while in therapy. Review of a physical therapy progress note dated 07/09/19 revealed Resident #66 was very lethargic and unable to participate fully with the treatment session. Documentation revealed the resident's nurse was to assess the resident's BP. Review of the nurse progress notes dated 07/04/19 revealed no evidence of nursing assessing Resident #66 or of the physician being notified of the residents varying BP during physical therapy. Review of the nurse progress notes dated 07/05/19, 07/07/19 and 07/08/19 revealed no evidence of physician notification for the low BP readings. Review of the nurse progress notes dated 07/09/19 at 3:17 P.M. revealed the residents BP was 80/50. Resident #66 was assessed with [REDACTED]. Documentation revealed the cardiologist was notified of the residents change of condition and faxed a medication list, vital signs and recent laboratory results. Review of the nurse progress note dated 07/10/19 at 9:59 [NAME]M. revealed new orders for antihypertensive medication adjustments were received from the cardiologist. Review of the nurse progress notes dated 07/11/19 at 5:10 P.M. revealed the resident was noted to have multiple low BP readings and medication changes had little effects. The resident complained of feeling lethargic, decreased appetite, and the inability to participate with therapy services due to symptoms. The physician was notified and a new order was obtained to send the resident to the hospital for evaluation and treatment. Review of hospital documentation dated 07/11/19 at 5:39 P.M. revealed the resident was sent to the local emergency department. Resident #66's vital signs were BP 91/57 mmHg, temperature 98.5 degrees Fahrenheit, respirations 15, and oxygen saturation 97 percent. Clinical impression included generalized weakness, [MEDICAL CONDITION],acute kidney injury, and transaminitis. Documentation revealed the resident was to be transferred to another hospital were the resident's specialist was located. Telephone interview on 10/03/19 at 8:42 [NAME]M. with the primary care physician for Resident #66 revealed the physician could not recall if the facility called to notify of the low BP assessments. Interview on 10/03/19 at 8:57 [NAME]M. with physical therapy assistant (PTA) #302 revealed the PTA worked with Resident #66 frequently. PTA #302 revealed Resident #66's therapy sessions were often shortened because the resident was lethargic and did not feel well. PTA #302 revealed the resident's BP would often drop during treatment sessions. The PTA reported nursing was made aware when the resident had low BP readings. The PTA had no knowledge if the doctor was made aware of the resident having BP reading concerns during therapy sessions. Interview on 10/03/19 at 9:13 [NAME]M. with licensed practical nurse (LPN) #304 revealed residents who were skilled had their BP assessed every eight hours for the first three days, then every 72 hours while the resident was skilled, and then weekly. BP would be monitored more often if a resident had physician ordered BP medications such as an antihypertensive medication that had parameters with medication administration. LPN #304 revealed a BP reading should be reported to the physician any time the BP dropped below the residents baseline. The LPN revealed per nursing judgment, antihypertensive medication should be held and the doctor notified for further instruction anytime a residents systolic BP falls below 100, unless the resident had physician ordered BP parameters. LPN #304 revealed Resident #66 did not have orders for monitoring the resident's BP prior to the administration of antihypertensive medications. LPN #304 verified antihypertensive medication was administered to Resident #66 on 07/05/19, 07/06/19, 07/07/19, and 07/08/19. The LPN further verified Resident #66's BP was below his baseline on 07/05/19, 07/06/19, 07/07/19, and 07/08/19. LPN #304 verified the residents physician should have been notified of the low BP assessment on 07/05/19 when the residents BP was 92/60. The LPN further verified the physician should have also been notified immediately of the low BP readings on 07/06/19, 07/07/19, and 07/08/19. The LPN confirmed the medical record for Resident #66 contained no evidence of the primary care physician or the cardiologist being notified of the residents low BP readings until 07/09/19, four days after the residents initial low BP reading was obtained. Interview on 10/03/19 at 10:09 [NAME]M. with the cardiologist revealed the facility called the cardiology office on 07/09/19 to inform them Resident #66 was experiencing low BP readings. The cardiologist's nurse returned a call to the facility on [DATE] to have Resident #66 sent to the hospital for evaluation and treatment. The cardiologist revealed after speaking with the facility on 07/10/19 it was decided not to send the resident to the hospital but rather make medication adjustments at the facility. The cardiologist revealed it would be expected that the facility would have notified the cardiologist or the primary care physician immediately of the initial low BP of 82/52 that was assessed on 07/07/19. The cardiologist verified the facility did not notify the cardiologist of Resident #66's low BP readings until 07/09/19. Review of a policy titled, Notification of Change undated, revealed the facility will consult with the resident's physician when there is a significant change in the residents physical, mental, or psychosocial status (that is deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications).

Based on record review, policy review, family and staff interview, the facility failed to ensure one resident's oxygen tank was not empty while in user by the resident. This affected one of one (#22) of one resident reviewed for respiratory care. The facility identified 19 resident's who currently receive respiratory treatments. The census was 64. Findings include: Review of Resident #22's medical record indicated the resident was admitted to facility 07/16/14. [DIAGNOSES REDACTED]. Resident #22's quarterly minimum data set (MDS) assessment dated [DATE], indicated the resident had severe cognitive impairment and required total dependence on staff for activities of daily living including bed mobility, transfers, locomotion, dressing, hygiene and extensive assistance with eating. The resident was admitted to hospice care on 09/07/17 with the [DIAGNOSES REDACTED]. Review of Resident # 22's plan of care dated 07/016/14 through 09/27/18 indicated the resident had altered respiratory status related to low energy, fatigue and shortness of breath. Interventions included provide oxygen as ordered. Interview on 08/20/18 at 6:38 P.M. with Resident #22's family member stated often when she visits, Resident #22's oxygen is not running. Observations on 08/21/18 at 7:25 A.M., revealed Resident #22 was sitting in the common area in front of the nurses station. The resident had a nasal cannula in her nose with the tubing attached to a oxygen tank. The gauge on the tank indicated the oxygen tank was empty. The resident did not appear to be in any respiratory distress. Interview with Licensed Practical Nurse (LPN) #47 on 08/21/18 at 7:25 A.M., verified the resident's oxygen tank was empty. LPN #47 stated the resident had been up for about five minutes and that the oxygen tank should of been changed when the tank was close to empty. Interview on 08/22/18 at 1:47 P.M., with the Director of Nursing (DON) stated, staff should be doing spot checks of the tanks to ensure they do not run out of oxygen. The DON identified 19 resident's who currently receive respiratory treatments. Review of the facility's undated policy titled Oxygen Therapy indicated the oxygen tanks should be checked every shift and as needed to ensure adequate supply in tank.

Based on review of a Self-Reported Incident, review of the facility's abuse policy, record review and staff interview, the facility failed to ensure one resident was free from physical abuse. This affected one (#1) of three residents reviewed and had the potential to affect all 63 residents of the facility. Findings include: Review of the medical record for Resident #1 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/01/18, revealed the resident had impaired cognition. The resident required limited to extensive assistance of two staff for bed mobility, transfers and toileting. Review of behavior assessment indicated the resident had no behavioral symptoms. Review of a nursing progress note dated 11/03/17 as a late noted for 10/31/17, stated the nurse was notified that during personal care Resident #1 struck out at a State tested Nursing Assistant (STNA) and hitting the STNA in the stomach. Then the STNA reactively struck the resident in right upper thigh. A head to toe assessment revealed no evidence of injury. No redness or bruising to right upper thigh was noted at this time. No complaints of or evidence of pain with assessment. Review of SRI # 6,dated 10/31/17,indicated on 10/31/17 at 4:00 P.M. STNA #25 reported to Licensed Practical Nurse (LPN) #35 that during personal care Resident #1 struck out, hitting STNA #50 in the stomach. STNA #25 witnessed STNA #50 reactively strike Resident #1 in the right upper thigh area. STNA #25 ensured resident safety and removed STNA #50 from the room, escorting her to the nurse and the Director of Nursing (DON) to report the incident. STNA #50 admitted to the DON she struck Resident #1 stating it was a reflex. STNA #50 was removed from the building by the DON. LPN #36 and the DON completed a head to toe assessment of Resident #1. STNA #25 stated the resident had no visible response or reaction to the physical contact from STNA #50. The physician was notified of the incident and assessment findings. The resident's daughter was also notified. Interview on 11/17/17 at 8:53 A.M., STNA #25 stated on 10/31/17 around 3:45 P.M. she was changing the Resident #1 with STNA #50. STNA #25 stated the resident will normally stand in the bathroom, but at that time refused to stand. STNA #50 and STNA #24 changed the resident in bed. STNA #25 stated the resident became combative during the care and hit the STNA #50 in the stomach. STNA #50 then responsively slapped the SR in the upper thigh. The sound of the smack was loud. STNA #25 stated after STNA #50 hit the resident, she asked her what she was doing and immediately took the resident out of the room with STNA #50 following her. STNA #25 stated she immediately reported the incident to LPN #35. STNA #25 and LPN #35 went with the resident to the DON. STNA #50 followed them. STNA #25 stated when it happened, Resident #1 did not say anything. She had a worried look on her face but she did not cry out in pain. Interview on 11/17/17 at 11:10 A.M., the DON stated around 3:50 P.M. on 10/31/17 STNA #25 and LPN #35 came to her and reported that during care the resident hit STNA# 50 and STNA #50 then hit the resident in the thigh. The DON stated she asked STNA #50 what happened and she told her Resident #1 hit her so she smacked her back on the leg. The DON stated the facility completed an investigation and substantiated physical abuse. Review of the undated facility policy titled Abuse/Neglect/ Misappropriation of Resident Property revealed residents of the long-term care facility are protected from any physical, mental, sexual, mistreatment, neglect, abuse, injuries of unknown source, use of corporal punishment, involuntary seclusion and misappropriation of resident property. This deficiency substantiates Complaint Number OH 538.

Based on review of a Self-Reported Incident, review of the facility abuse policy, record review and staff interview, the facility failed to implement their abuse policy to ensure one resident was free from physical abuse. This affected one (#1) of three residents reviewed and had the potential to affect all 63 residents of the facility. Findings include: Review of the medical record for Resident #1 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/01/18, revealed the resident had impaired cognition. The resident required limited to extensive assistance of two staff for bed mobility, transfers and toileting. Review of behavior assessment indicated the resident had no behavioral symptoms. Review of a nursing progress note dated 11/03/17 as a late noted for 10/31/17, stated the nurse was notified that during personal care Resident #1 struck out at a State tested Nursing Assistant (STNA) and hitting the STNA in the stomach. Then the STNA reactively struck the resident in right upper thigh. A head to toe assessment revealed no evidence of injury. No redness or bruising to right upper thigh was noted at this time. No complaints of or evidence of pain with assessment. Review of SRI # 6,dated 10/31/17,indicated on 10/31/17 at 4:00 P.M. STNA #25 reported to Licensed Practical Nurse (LPN) #35 that during personal care Resident #1 struck out, hitting STNA #50 in the stomach. STNA #25 witnessed STNA #50 reactively strike Resident #1 in the right upper thigh area. STNA #25 ensured resident safety and removed STNA #50 from the room, escorting her to the nurse and the Director of Nursing (DON) to report the incident. STNA #50 admitted to the DON she struck Resident #1 stating it was a reflex. STNA #50 was removed from the building by the DON. LPN #36 and the DON completed a head to toe assessment of Resident #1. STNA #25 stated the resident had no visible response or reaction to the physical contact from STNA #50. The physician was notified of the incident and assessment findings. The resident's daughter was also notified. Interview on 11/17/17 at 8:53 A.M., STNA #25 stated on 10/31/17 around 3:45 P.M. she was changing the Resident #1 with STNA #50. STNA #25 stated the resident will normally stand in the bathroom, but at that time refused to stand. STNA #50 and STNA #24 changed the resident in bed. STNA #25 stated the resident became combative during the care and hit the STNA #50 in the stomach. STNA #50 then responsively slapped the SR in the upper thigh. The sound of the smack was loud. STNA #25 stated after STNA #50 hit the resident, she asked her what she was doing and immediately took the resident out of the room with STNA #50 following her. STNA #25 stated she immediately reported the incident to LPN #35. STNA #25 and LPN #35 went with the resident to the DON. STNA #50 followed them. STNA #25 stated when it happened, Resident #1 did not say anything. She had a worried look on her face but she did not cry out in pain. Interview on 11/17/17 at 11:10 A.M., the DON stated around 3:50 P.M. on 10/31/17 STNA #25 and LPN #35 came to her and reported that during care the resident hit STNA# 50 and STNA #50 then hit the resident in the thigh. The DON stated she asked STNA #50 what happened and she told her Resident #1 hit her so she smacked her back on the leg. The DON stated the facility completed an investigation and substantiated physical abuse. Review of the undated facility policy titled Abuse/Neglect/ Misappropriation of Resident Property revealed residents of the long-term care facility are protected from any physical, mental, sexual, mistreatment, neglect, abuse, injuries of unknown source, use of corporal punishment, involuntary seclusion and misappropriation of resident property. This deficiency substantiates Complaint Number OH 538.