Every finding on record at Vancrest of Upper Sandusky

Based on observations, staff interviews, review of facility policy, and review of a medication reference guide, the facility failed to ensure medications were properly labeled with an open date to determine expiration dates and further failed to ensure expired medications were disposed of. This had the potential to affect all 89 residents residing in the facility. The facility census was 89.Findings include: 1. Observation on 01/13/26 at 9:22 A.M. of the Buckeye Hall medication cart revealed a bottle of GenTeal tears (for dry eyes) for Resident #90, with a delivery date of 10/18/25 and no open date. Concurrent interview with Registered Nurse (RN) #123 verified there was no open date on Resident #90's GenTeal tears to indicate when they should be discarded. 2. Observation on 01/13/25 at 9:41 A.M. of the Stepping Stones Hall medication cart revealed the following: a Lantus SoloStar 100 units/milliliters (u/ml) insulin pen , with a delivery date of 11/01/25 and no open date for Resident #38; an insulin degludec FlexTouch 100 u/ml insulin pen, with a delivery date of 11/24/25 and no open date for Resident #7; a bottle of artificial tears 0.5 fl oz with no open date for Resident #87; and a bottle of Refresh Tears lubricant eye drops 0.5 fl oz with no open date for Resident #77. Concurrent interview with RN #140 verified the medications were not labeled with the date they were opened. 3. Observation on 01/13/25 at 9:15 A.M. of the Stepping Stone Hall storage unit revealed a vial of Aplisol (tuberculin purified protein derivative solution used in the standard Mantoux tuberculosis [TB] skin test). The label on the vial stated, Do not use 30 days after above date, with an open date of 11/26/25. Concurrent interview with RN #140 verified the Aplisol was past the 30-day expiration date and further confirmed it was available for any resident who required TB testing.4. Observation on 01/14/25 at 8:20 A.M. of the west medication cart revealed three unidentified pills (one white pill, one black pill, and one small lavender pill) in a medication cup sitting in the second drawer of the medication cart. Further observation revealed multiple bottles of Refresh Tears lubricant eye drops 0.5 fl oz. that did not have a resident name or open dates; two Lantus SoloStar insulin pens for Resident #45 with no open date; a bottle of Pataday (eye drops for allergies) with no open date for Resident #58; a bottle of latanoprost 0.005% eye drops, with a delivery date of 12/02/25 and no open date for Resident #45; and a bottle of Systane lubrication eye drops with no resident name and an open date of 11/27/25. Concurrent interview with Licensed Practical Nurse (LPN) #307 verified the findings.5. Observation on 01/14/25 at 8:35 A.M. of the north medication cart revealed an albuterol sulfate inhalation aerosol 90 microgram (mcg) per actuation inhaler with an open date of 08/28/25. Further observation of the label revealed the inhaler expired 90 days after opening (90 days from opening was 11/26/25). Concurrent interview with LPN #317 verified the albuterol sulfate inhaler was expired.Review of the medical reference, The International Pharmacopoeia-Thirteenth Edition, dated 2025, revealed multidose ophthalmic drop preparations may be used for up to four weeks after the container was initially opened.Review of the Lantus SoloStar pharmaceutical safety information, dated 2022, revealed to throw away an opened Lantus SoloStar pen, even if it still had insulin in it, after 28 days.Review of the insulin degludec FlexTouch injection pen pharmaceutical safety information, dated 2024, revealed to dispose of the pen after eight weeks, even if there was insulin left in the pen or vial and the expiration date had not passed.Review of the facility policy titled, Medication Labeling and Storage, dated February 2023, revealed if the facility had discontinued or outdated medication, the dispensing pharmacy was contacted for instructions regarding returning or destroying these items. Over the counter (OTC) medications should have a label that contained the medication names, strength, quality, accessory instructions, lot number and expiration date. Multi-dose vials that had been opened or accessed were dated and discarded within 28 days unless the manufacturer specified a shorter or longer date.Review of the facility policy titled, Administering Medications, dated April 2019, revealed when opening a multi-dose container, the date opened was recorded on the container.

Based on observation and staff interview, the facility failed to ensure the confidentiality of residents' medical information. This affected 13 (#7, #11, #15, #17, #26, #36, #38, #55, #59, #62, #67, #83, and #87) of 13 residents who resided on the east hall. The facility census was 89.Findings include:Observation on 01/13/26 at 8:20 A.M. revealed Licensed Practical Nurse (LPN) #307 walked away from her medication cart on the East Hall for four minutes. LPN #307 left a sheet of paper laying on top of the medication cart, within view, that had the names, room numbers, and medical information, which included vital signs, blood sugar and laboratory (lab) results, and resident behaviors, for the 13 (#7, #11, #15, #17, #26, #36, #38, #55, #59, #62, #67, #83, and #87) residents who resided on the East Hall. Interview on 01/13/26 at 8:24 A.M. with LPN #307 verified she left confidential resident information unsecured on top of the medication cart. LPN #307 stated, I will work on this.Observation on 01/13/26 at 11:05 A.M. revealed LPN #307 walked away from her medication cart on the main hallway in front of the nurses' station for eight minutes. LPN #307 left a sheet of paper laying on top of the medication cart, within view, that had the names, room numbers, and medical information, which included vital signs, blood sugar and lab results, and resident behaviors, for the 13 (#7, #11, #15, #17, #26, #36, #38, #55, #59, #62, #67, #83, and #87) residents who resided on the East Hall. Continued observation revealed two visitors stopped at the mediation cart and looked the paper for approximately thirty seconds and walked away. Multiple staff and residents walked by the cart before LPN #307 returned.Interview on 01/13/26 at 11:14 A.M. with LPN #307 verified she left confidential resident information on top of the medication cart and it was accessible to anyone who passed the medication cart.

Based on medical record review and staff interview, the facility failed to ensure comprehensive care plans were developed to address residents' needs. This affected four (#2, #64, #84 and #10) of four residents reviewed for care plans. The facility census was 89. Findings include:1. Review of the medical record for Resident #2 revealed she was admitted on [DATE]. Her diagnoses included dementia, hypertension, glaucoma, malnutrition, and a stage three pressure ulcer to her upper back. Her Braden assessment (used to predict the risk for pressure ulcers) revealed she was at risk for pressure ulcers. Review of the Minimum Data Set (MDS) assessment, dated 12/12/25, revealed Resident #2 was cognitively impaired and did not experience behaviors at the time of the assessment. Resident #2 was incontinent and dependent on staff for bed mobility and transfers. Resident #2 was at risk for pressure ulcers. Review of Resident #2's current care plan revealed turning and repositioning was not implemented as an intervention for the prevention of pressure ulcers. Interview on 01/14/26 at 9:20 A.M. with the Director of Nursing (DON) revealed turning and repositioning every two hours was a standard of care for the prevention of pressure ulcers and should be a care plan intervention for residents at risk for pressure ulcer development. The DON verified turning and repositioning was not a care planned intervention for Resident #2 and should have been. 2. Review of the medical record for Resident #64 revealed she was admitted on [DATE]. Her diagnoses included intracerebral hemorrhage, dysphagia, chronic obstructive pulmonary disease (COPD), cognitive communication deficit, hemiplegia and hemiparesis to the left side, hyperlipidemia, depression, and anxiety. Her Braden assessment revealed she was at risk for pressure ulcers. Review of the MDS assessment, dated 10/18/25, revealed Resident #64 was cognitively intact and did not display any behaviors at the time of the assessment. She experienced functional range of motion (ROM) limitations to her left upper extremity and to her bilateral lower extremities. She utilized a wheelchair and was dependent for transfers. Resident #64 required substantial assistance with bed mobility and activities of daily living (ADLs) and was at risk for pressure ulcers. Review of Resident #64's current care plan revealed turning and repositioning was not implemented as an intervention for the prevention of pressure ulcers. Interview on 01/14/26 at 9:20 A.M. with the DON revealed turning and repositioning every two hours was a standard of care for the prevention of pressure ulcers and should be a care plan intervention for residents at risk for pressure ulcer development. The DON verified turning and repositioning was not a care planned intervention for Resident #64 and should have been. 3. Review of the medical record for Resident #84 revealed he was admitted on [DATE]. His diagnoses included heart disease, deep vein thrombosis, hypertension, obstructive sleep apnea, basal cell carcinoma, dementia, difficulty walking, and cerebral infarction (stroke). His Braden assessment revealed he was at risk for pressure ulcers. Review of the MDS assessment, dated 12/16/25, revealed Resident #84 was mildly cognitively impaired and did not exhibit behaviors at the time of the assessment. Resident #84 was incontinent, required substantial assistance with bed mobility and transfers, and was at risk for pressure ulcers. Review of Resident #84's current care plan revealed turning and repositioning was not implemented as an intervention for the prevention of pressure ulcers. Interview on 01/14/26 at 9:20 A.M. with the DON revealed turning and repositioning every two hours was a standard of care for the prevention of pressure ulcers and should be a care plan intervention for residents at risk for pressure ulcer development. The DON verified turning and repositioning was not a care planned intervention for Resident #84 and should have been. 4. Review of the medical record for Resident #10 revealed an admission date of 09/20/25 with diagnoses including, but not limited to, dementia with other behavioral disturbance, cognitive communication deficit, and anxiety. Review of the MDS assessment, dated 11/18/25, revealed the resident had severe cognitive impairment with inattention behaviors that fluctuated. Resident #10 had physical and verbal behaviors directed towards others one to three days of the seven-day look-back period. Review of current physician orders revealed the resident was on Seroquel (antipsychotic medication) 25 milligrams (mg) for anxiety twice daily. Review of care plan dated 06/13/25 revealed no care plan was initiated or implemented related to Resident #10's use of antipsychotic/psychotropic medication. Interview on 01/14/26 at 7:43 A.M. with the DON confirmed Resident #10 did not have a care plan for psychotropic medication usage. The DON further verified Resident #10 should have had a care plan focus area, with interventions, in place for the use of psychotropic medications. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed the comprehensive, person-centered care plan included measurable objectives and timeframes, described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and reflected currently recognized standards of practice for problem areas and conditions.

Based on observation, review of the activity calendars, staff interview, and review of facility policy, the facility failed to ensure an adequate activities program on the memory care unit. This had the potential to affect 12 (#13, #14, #47, #53, #57, #60, #63, #68, #78, #80, #82, and #89) residents identified by the facility as residing on the memory care unit and regularly participating in activities. The facility census was 89.Findings include:Review of the Activity Calendar for 01/12/26 revealed the following scheduled activities on the memory care unit: 9:30 A.M. morning music, 10:30 A.M. just you and me, 1:00 P.M. hydration station, and 3:00 P.M. piano with Resident Council President.Observation on 01/12/26 from 9:00 A.M. through 10:40 A.M. of the memory care unit revealed no activities were occurring. Residents were observed in the dining room for breakfast or sitting in the common area in front of the television (TV) sleeping.Observation on 01/12/26 at 1:25 P.M. of the memory care unit revealed no activities were occurring on the unit. Review of the Activity Calendar for 01/13/26 revealed the following activities: 10:30 A.M. greet the day, 11:00 A.M. lunch friends, 1:00 P.M. refreshment time, 2:00 P.M. let's get moving, 2:30 P.M. music with [NAME], and 4:00 P.M. winter memories.Observation on 01/13/26 at 10:06 A.M. of the memory care unit revealed six residents were sitting in the back common area watching TV. Two of those residents were sleeping, with one resident asleep in her wheelchair with her head bobbing back and then back to the front toward her chest. Continued observation revealed one resident was asleep in front of the TV in the front hall common area. No staff were observed to be interacting with the residents in the common areas.Observation on 01/13/26 at 10:24 A.M. revealed Activities Aide (AA) #212 was in the back common area of the memory care unit. AA #212 cleared off the table, which had magazines and puzzles on it. AA #212 was observed with an activity cart.Observation on 01/13/26 at 10:39 A.M. of the memory care unit revealed no scheduled activity was occurring. Continued observation revealed activities staff gathered hot water to make tea for residents. One resident was observed to be sitting at the table. Four residents were sitting around the TV. At 10:44 A.M., a total of three residents were sitting at the table for tea. A visitor arrived to the unit with their dog and visited with the residents, allowing them to pet the dog. Several residents were observed petting the dog and talking about the pets they used to have. Staff were observed to begin taking residents to the dining room for lunch. Interview on 01/13/26 at 11:28 A.M. with AA #12 revealed that within the past month, different activities had been done at the kitchen table, including music, snacks, crafts, and exercise. AA #212 stated greet the day was everyday, which included one-on-ones in resident rooms. AA #212 stated they no longer had a pastor that came regularly for church services. AA #212 stated that she did inspirational corner, where she sings hymns for the residents.Interview on 01/13/26 at 1:39 P.M. with AA #212 revealed she was on another unit in the facility on 01/12/26, so no activities were completed on the memory care unit. AA #212 stated that she went to the memory care unit around noon and talked to a few residents. AA #212 stated they only had two activity aides and verified no activities were done on the memory care unit on 01/12/26. Observation on 01/13/26 at 1:54 P.M. of the front common area revealed residents were being brought down for an exercise activity scheduled at 2:00 P.M. Three residents were present for the activity. AA #212 proceeded to turn on music and lead the residents through stretches and exercises. Interview with AA #212 revealed the 2:30 P.M. activity, music with [NAME], would not be occurring as he no longer came to the facility. AA #212 stated the activity had not been replaced yet and she had to be on another unit at 2:30 P.M. to lead a music activity. Continued observation revealed two additional residents and family members came to the common area for the 2:30 P.M. music activity and AA #212 informed them he was no longer coming and the activity would not take place. The residents and family members were observed leaving the common area. After the exercises, all but one resident left the area. Review of the Activity Calendar for 01/14/26 revealed the following activities: 10:30 A.M. greet the day, 11:00 A.M. lunch friends, and 1:00 P.M. refreshment time.Observation on 01/14/26 at 10:39 A.M. of the memory care unit common area revealed two residents in wheelchairs were sleeping in front of the TV, one resident was observed sitting at the table asleep, and one resident was drinking fluids. No activity was observed to be occurring and no staff were observed interacting with the residents in the common area. Interview on 01/14/26 at 10:49 A.M. with Licensed Practical Nurse (LPN) #232 revealed that AA #212 would not be on the memory care unit until 1:00 P.M. as it was her late night. LPN #232 confirmed the scheduled activities did not occur that morning and none would be done until AA #212 came in. LPN #232 stated Activities Director (AD) #278 would help with activities. Interview on 01/14/26 at 10:58 A.M. with AD #278 verified no activities occurred on the memory care unit on 01/12/26. AD #278 stated she talked to the residents all the time, but confirmed talking to residents was not an activity. Review of the facility policy titled, Activity Programs, revised June 2018, revealed the activities program was provided to support the well-being of residents and to encourage both independence and community interaction. Activities offered were based on the comprehensive resident-centered assessment and the preferences of each resident. Activities were scheduled seven days a week and residents were given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure mechanically altered meals were stored in a manner to prevent contamination. This affected six (#2, #8, #16, #51, #74, #79, and #84) of six residents identified by the facility as receiving pureed foods. Additionally, the facility failed to ensure the kitchenette was maintained in a clean and sanitary manner. This affected 37 (#4, #5, #6, #9, #12, #16, #20, #22, #27, #28, #31, #33, #34, #37, #39, #40, #41, #44, #46, #50, #51, #56, #58, #61, #67, #70, #71, #75, #79, #85, #86, #88, #90, #91, #92, #94, and #100) of 37 residents who received food from the second floor kitchenette. The facility census was 89.Findings include:1. Observation on 01/12/26 at 9:30 A.M. revealed [NAME] #210 prepared puree meals, consisting of breaded fish and broccoli, for the lunch meal. [NAME] #210 placed the pureed foods into twelve single-serve bowls, covered the bowls with lids, labeled and dated the lids, then placed them on a room temperature preparation (prep) table. Interview on 01/12/26 at 9:45 A.M. with [NAME] #210 confirmed the prepared pureed foods were placed on the prep table and further stated the foods were neither refrigerated nor warmed until lunch service at 11:30 A.M. (two hours after preparation). Interview on 01/12/26 at 9:55 A.M. with Dietary Manager (DM) #233 verified prepared foods should be refrigerated after preparation. Review of the facility policy titled, General Food Preparation and Handling, dated 2005, revealed foods would be refrigerated to below 40 degrees Fahrenheit (F) immediately after preparation. 2. Observation on 01/14/26 at 10:37 A.M. of the second-floor kitchenette revealed a drying towel hanging over the sink. Further observation of the kitchenette revealed a dried, clear, sticky substance on the ice machine, an unknown dried white substance scattered on the cupboards under the sink, and a large amount of food debris in the reach in refrigerator. Additional observation of the kitchenette revealed a large amount of food debris built up in the microwave. Interview on 01/14/26 at 10:45 A.M. with Dietary Aide (DA) #242 revealed the drying towel hanging over the sink was used for the clean dishes that came out of the dish washer. DA #242 confirmed that the towel was to be changed after each meal, however the towel drying over the sink was the same towel used 01/13/26. DA #242 verified the sticky substance on the ice machine, the white substance on the cupboards under the sink, and the food debris in the refrigerator and microwave. Review of the facility policy titled, General Sanitation of Kitchen, dated 2005, revealed the staff shall maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule.

Based on medical record review, observation, family and staff interview, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to perform hand hygiene during medication administration and further failed to ensure nebulizer tubing was stored in a sanitary manner. This affected one (#5) of 13 residents observed for medication administration. Additionally, the facility failed to ensure residents with respiratory illness were placed on transmission-based precautions (TBP). This affected one (#64) of one resident reviewed for respiratory illness. The facility census was 89. Findings include:1. Review of the medical record for Resident #5 revealed an admission date of 03/26/18. Diagnoses included contusion, laceration, and hemorrhage of brainstem with loss of consciousness of unspecified duration, aphasia, nontraumatic intracerebral hemorrhage, hemiplegia, and hemiparesis following cerebral infarction (stroke) affecting left non-dominant side. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/25/25, revealed Resident #5 had severe cognitive impairment and was dependent on staff for daily care. Further review of the MDS revealed Resident #5 required tracheostomy care and required a feeding tube for nutrition. Review of the current care plan revealed Resident #5 received nourishment via a percutaneous endoscopic gastrostomy (peg) tube (feeding tube surgically placed through the abdominal wall directly into the stomach to deliver nutrition, fluids, and medication) related to the inability to take nourishment by mouth due to traumatic brain injury (TBI) and tracheostomy. Additionally, Resident #5 was in enhanced barrier precautions (EBP-infection control measures, including the use of gowns and gloves during high-contact care, to reduce the spread of multidrug-resistant organisms [MDROs]). Observation on 01/14/26 at 11:24 A.M. of medication administration revealed Licensed Practical Nurse (LPN) #307 prepared medications for administration to Resident #5. LPN #307 did not complete hand hygiene before medication preparation or after administering Resident #5's medication. Further observation of Resident #5's room revealed a nebulizer machine, with the tubing hanging off the bedside table onto the floor, and the breathing tube on a paper towel on the bedside table. Interview on 01/14/26 at 11:32 A.M. with LPN #307 verified she did not perform hand hygiene prior to preparing and administering Resident #5's medications, or after she completed administration. Additionally, LPN #307 verified the resident's nebulizer tubing was laying on the floor, with the breathing tube placed on a paper towel on the bedside table. LPN #307 confirmed the tubing should have been placed in a bag to ensure sanitary storage. LPN #307 verified there was no bag in Resident #5's room for the storage of the resident's nebulizer tubing and stated she would get one to ensure it was properly stored. Review of the facility policy titled, Standard Precautions, dated September 2022, revealed hand hygiene was performed with alcohol-based hand rub (ABHR) or soap and water before and after contact with a resident and after the removal of gloves. Review of facility policy titled, Breathing Treatment Machine Cleaning and Storage Policy, undated, revealed clean nebulizer components and tubing shall be stored in a clean, labeled container or bag. 2. Review of the medical record for Resident #64 revealed she was admitted on [DATE]. Her diagnoses included intracerebral hemorrhage, dysphagia, chronic obstructive pulmonary disease (COPD), cognitive communication deficit, hemiplegia and hemiparesis to the left side, hyperlipidemia, depression, and anxiety. Review of the MDS assessment, dated 10/18/25, revealed Resident #64 was cognitively intact and did not display any behaviors at the time of the assessment. She experienced functional range of motion (ROM) limitations to her left upper extremity and to bilateral lower extremities. She utilized a wheelchair and was (staff) dependent for transfers. Resident #64 required substantial assistance with bed mobility and activities of daily living (ADLs). Review of a progress note for Resident #64 revealed on 01/09/26 at 12:49 P.M., the resident had congestion and a dry barking cough. Her lung sounds were coarse and wheezy and she required oxygen supplementation. At 1:57 P.M. a progress note revealed new medications were ordered due to abnormal lung sounds and shortness of breath. Review of a nursing respiratory assessment dated [DATE] for Resident #64 revealed abnormal breath sounds of wheezing and rhonchi (low-pitched rattling lung sounds) in all lung fields. Resident #64 also experienced shortness of breath and a non-productive cough. Review of the physician orders dated 01/09/26 for Resident #64 revealed an order for a one time chest X-ray, an order for ipratropium-albuterol inhalation solution 0.5-2.5 three milligrams (mg) per milliliter (mL) to be administered three times a day for three days for wheezing, and an order for 20 mg of prednisone to be administered daily at bedtime for five days for wheezes and rhonchi. Additionally, there was an order dated 01/13/25 to re-start the ipratropium-albuterol inhalation solution 0.5-2.5 three mg per mL to be administered three times a day for five days for wheezing. Review of a physician note for Resident #64, dated 01/12/26, revealed a diagnosis of acute bronchitis, shortness of breath, wheezing, and acute unspecified upper respiratory infection. Further review revealed prolonged isolation and limited contact with family and friends, increase fluids and COVID protocol per policy. Interview on 01/12/26 at 10:30 A.M. with Resident #64's spouse revealed Resident #64 had an unspecified respiratory infection. Concurrent observation revealed no signage or other evidence Resident #64 was on TBP. Observations on 01/13/26 at 9:20 A.M., 01/14/26 at 8:42 A.M., and 01/15/26 at 10:45 A.M. of Resident #64's room revealed no signage or other evidence Resident #64 was on TBP. Interview on 01/14/26 at approximately 3:00 P.M. with the Director of Nursing (DON) confirmed Resident #64 was not placed on TBP due to respiratory illness. Interview on 01/15/26 at 10:50 A.M. with Certified Nursing Assistant (CNA) #295 confirmed Resident #64 was not on TBP, nor had she been recently. Review of the facility policy titled, Respiratory Illness: Screening and Management, dated 11/09/23, revealed the facility would place residents with confirmed or suspected respiratory illness in TBP in a manner consistent with the CDC to prevent the transmission of communicable respiratory infections. Further review of this policy revealed symptoms that warranted following the above noted procedure included new cough and shortness of breath. Review of the CDC guidelines titled, Transmission-Based Precautions, dated 04/03/24, revealed to use droplet precautions for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who was coughing, sneezing, or talking. Further review revealed to use personal protective equipment (PPE) by donning a mask upon entry to the patient's room or patient's space.

Based on medical record review, observation, and resident and staff interview, the facility failed to ensure timely follow-up on hearing needs. This affected one (#28) of one resident reviewed for hearing services. The facility census was 89.Findings include:Review of the medical record for Resident #28 revealed an admission date of 12/10/19 and a re-admission date of 11/03/23. Diagnoses included diabetes mellitus Type II, chronic obstructive pulmonary disease (COPD), and major depressive disorder. Review of the annual Minimum Data Set (MDS) assessment, dated 11/21/25, revealed Resident #28 had moderate cognitive impairment. Further review of the MDS revealed Resident #28 had moderate difficulty with hearing and wore hearing aids. Review of the care plan dated 11/03/23 revealed Resident #28 had a communication problem related to hearing deficit. Interventions included bilateral hearing aids. Review of the physician orders dated 06/25/25 revealed Resident #28 had an order to offer to put hearing aids in the morning and document Resident #28's wishes. Further review revealed an order dated 06/25/25 to remove Resident #28's hearing aids at night and store in the medication cart.Review of the audiology progress report dated 08/25/25 revealed Resident #28 was seen for a hearing evaluation. Findings from the audiology appointment included bilateral moderate hearing loss. New orders included continued use of the right hearing aid, turn volume of the hearing aid all the way up.Review of the Medication Administration Record (MAR) for January 2026 revealed from 01/01/26 through 01/13/26, staff documented Resident #28 wore his hearing aids and they were placed in the medication cart at nighttime.Review of the nurse progress notes from 01/01/26 through 01/13/26 revealed no documentation of Resident #28's right hearing aid missing.Observation on 01/13/26 at 8:47 A.M. revealed Resident #28 sitting in his recliner chair with his feet elevated. Resident #28 had a hearing aid in the left ear. Concurrent interview with Resident #28 revealed the resident had difficulty understanding what was said to him by the surveyor as he was not able to hear. Resident #28 stated his right hearing aid had been missing for an extended period, adding he placed the hearing aid on his bedside table months ago and it came up missing.Interview on 01/13/26 at 10:21 A.M. with Licensed Practical Nurse (LPN) #317 confirmed Resident #28's right hearing aid was lost. LPN #317 stated staff searched for months for the right hearing aid, without success in locating it. LPN #317 stated she reported the missing hearing aid to management, but did not specify who was notified. LPN #317 was unable to recall how long the right hearing aid had been missing; however, LPN #317 stated the right hearing aid was not functioning properly at the time it came up missing.Interview on 01/13/26 at 11:58 A.M. with the Director of Nursing (DON) confirmed she was unaware Resident #28's right hearing aid was missing and denied management was notified of the missing hearing aid. The DON verified that staff should have made her aware so that an appointment could have been scheduled to have it replaced.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure sanitary practice while caring for a urinary catheter. This affected one (#45) of two residents reviewed for urinary catheters. The facility census was 89.Findings include:Review of the medical record for Resident #45 revealed an admission date of 08/22/14 and a readmission date of 01/12/24. Diagnoses included Arnold Chiari Syndrome with spina bifida, paraplegia, neuromuscular dysfunction of the bladder, and obstructive and reflux uropathy, unspecified. Review of the annual Minimum Data Set (MDS) assessment, dated 11/30/25, revealed Resident #45 was cognitively intact. Further review of the MDS revealed Resident #45 was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 01/13/24 revealed Resident #45 was at risk for urinary tract infections (UTIs) related to neurogenic bladder, obstructive uropathy, and intermittent catheterization. Interventions included encourage fluids, laboratory (lab) draws, medications, and notify the provider of signs and symptoms of a UTI. Additionally, Resident #45 had potential for complications related to catheter related to paraplegia, neurogenic dysfunction of bladder, obstructive uropathy, and neurogenic bowel. Interventions included staff to provide perineal care and catheter care to site care as needed. Review of the physician orders dated 01/07/26 revealed Resident #45 had an order for gentamicin sulfate injection solution (antibiotic), 480 milligrams (mg) via irrigation every day shift for bladder irrigation, 60 milliliters (ml) by bladder. Gentamicin 480 mg in one liter of 0.9 percent (%) normal saline. Instill 60 ml into the bladder, clamp off catheter for one hour, then drain.Observation on 01/14/26 at 9:39 A.M. revealed Licensed Practical Nurse (LPN) #302 cleansed around the skin of Resident #45's urinary catheter site with a wet wipe. LPN #302 did not clean the catheter tubing. Further observation revealed LPN #302 placed a 60 ml syringe into the gentamycin and normal saline solution, withdrawing 60 mls. LPN #302 then removed the urinary catheter bag and attached the 60 ml syringe to the catheter. LPN #302 pushed the gentamycin and normal saline solution into Resident #45's urinary catheter tubing and left the syringe connected to the urinary catheter tubing. LPN #302 then walked into Resident #45's bathroom. Continued observation revealed Resident #45 began coughing. While Resident #45 was coughing, fluid pushed from the urinary catheter back into the syringe, with notable sediment present. Resident #45 coughed again, expelling 60 mls total from the urinary catheter into the syringe. After the surveyor made LPN #302 aware that fluid was present in the syringe, LPN #302 pushed the fluid back into Resident #45's bladder and walked out of the room.Interview on 01/14/26 at 9:41 A.M. with LPN #302 confirmed that Resident #45's catheter care should be completed with warm soapy water, cleaning the catheter insertion site and down the tubing. LPN #302 confirmed she did not clean Resident #45's catheter with warm soapy water and further stated, Sometimes I do. LPN #302 verified she left the medication syringe connected to the urinary catheter tubing instead of clamping it because the clamp to the catheter did not work properly. LPN #302 stated she was unsure if it was sanitary to push the fluid that was expelled into the syringe when Resident #45 was coughing back into the resident's bladder.Interview on 01/14/26 at 11:15 A.M. with the Director of Nursing (DON) confirmed staff should clean around the urinary catheter site with warm soapy water, including going down the catheter tubing. The DON further confirmed Resident #45's catheter should have been clamped off and the syringe removed following the administration of the gentamicin and normal saline solution. The DON stated the fluid that was expelled into the syringe should not have been pushed back into Resident #45's bladder as it could cause obstruction or infection.Review of the facility policy titled, Catheter Care Policy, undated, revealed staff should inspect the suprapubic insertion site each shift for redness, swelling, drainage, or signs of infection. Cleanse the site daily with mild soap and water.Review of the facility policy titled, Urinary Catheter Irrigation Policy, undated, revealed catheter irrigation would be completed using aseptic technique to maintain a closed drainage system whenever possible and to minimize the risk of catheter-associated UTIs. Staff should clamp the drainage tubing, then unclamp tubing at ordered time to allow drainage into the collection bad.

Based on medical record review and staff interview, the facility failed to ensure respiratory assessments were completed following a change in condition. This affected one (#60) of one resident reviewed for respiratory care. The facility census was 89.Findings include:Review of the medical record for Resident #60 revealed an admission date of 06/19/24 with diagnoses including, but not limited to, type two diabetes, hypertension, major depressive disorder, chronic obstructive pulmonary disease (COPD), dementia, anxiety, and mild cognitive impairment.Review of the Minimum Data Set (MDS) assessment, dated 10/28/25, revealed the resident had severe cognitive impairment. Review of care plan dated 06/14/24 revealed Resident #60 had emphysema/COPD related to smoking. Resident #60 was noted to have lung nodules. Interventions included administer medications as ordered, apply oxygen as ordered, head of bed elevated, observe as needed for signs and symptoms of respiratory infection, and monitor respiratory rate, depth, and effort.Review of the physician orders dated 01/11/26 revealed Resident #60 was ordered azithromycin (antibiotic) 250 milligrams (mg) daily until 01/15/26 for cough/congestion, oxygen at two liters per minute (lpm), prednisone 20 mg daily for five days, and oxygen tubing- change, date, and initial weekly on Sunday. Review of the Respiratory Assessments revealed Resident #60 had assessments completed at least daily until 01/11/26. Further review revealed no assessments were completed after 01/11/26.Interview on 01/14/26 at 9:11 A.M. with the Director of Nursing (DON) revealed that if a resident had a history of respiratory disease or any new respiratory issues, the Respiratory Assessment was to be completed every shift. The DON verified the last Respiratory Assessment for Resident #60 was completed on 01/11/26 and they should have been completed on each shift. A follow-up interview on 01/14/26 at 11:20 A.M. with the DON revealed the protocol for residents receiving antibiotics, steroids, oxygen, and breathing treatments would be to complete an assessment, to include lung sounds, cough, and vital signs. The DON verified there was no documentation in Resident #60's medical record that the resident's respiratory issues, such as lung sounds, antibiotic use, and cough were assessed from 01/12/26 through 01/14/26.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure parameters were in place for the safe administration of as needed (PRN) pain medications. This affected two (#71 and #8) of five residents reviewed for unnecessary medications. The facility census was 89.Findings include:1. Review of the medical record for Resident #71 revealed she was admitted on [DATE]. Diagnoses included cirrhosis of the liver, bipolar disorder, anxiety, depression, acquired absence of parts of the digestive tract, malnutrition, sacroiliitis, low back pain, fibromyalgia, migraine, lesion of the right sciatic nerve, and osteoarthritis. Review of the Minimum Data Set (MDS) assessment, dated 12/31/25, revealed Resident #71 was cognitively intact and did not display any behaviors at the time of the assessment. Resident #71 utilized a walker and was either independent or required minimal assistance with activities of daily living (ADLs). She received scheduled and as-needed pain medication to manage frequent pain that affected her sleep and day-to-day activities. Review of the physician orders revealed Resident #71 had an order dated 12/11/23 for five milligrams (mg) of oxycodone hydrochloride (HCI) every 24 hours PRN for pain, an order dated 06/15/25 for a fentanyl transdermal patch, 12 micrograms (mcg) per hour to be changed every 72 hours for pain, an order dated 10/03/25 for butalbital-aspirin-caffeine 50-325-40 mg every six hours PRN for migraine pain, and an order dated 09/16/25 for five mg of oxycodone HCI twice daily for pain. The PRN pain medication orders did not include parameters for the administration of the medications. Review of the December 2025 Medication Administration Record (MAR) revealed Resident #71 was administered butalbital-ASA-caffeine oral capsule twice on 12/05/25, once on 12/06/25, once on 12/07/25, once on 12/10/25, once on 12/11/25, once on 12/20/25, and once on 12/21/25 for an assessed pain level of zero. Further review revealed additional butalbital-ASA-caffeine oral capsule doses were administered at least daily, with assessed pain levels ranging from one to 10 upon administration. Additionally, oxycodone HCI five mg oral tablet was administered on 12/02/25, 12/05/25, 12/06/25, 12/07/25, 12/18/25, 12/20/25, and 12/21/25 for an assessed pain level of zero. Further review revealed oxycodone HCI was administered 18 additional times during the month of December with assessed pain levels ranging from two to nine. Review of the January 2026 MAR, from 01/01/25 through 01/14/25, revealed butalbital-ASA-caffeine oral capsule was administered at least daily for assessed pain levels ranging from two to nine. Oxycodone HCI was administered 12 of the 14 days for assessed pain levels of two to eight. Interview on 01/14/26 at 3:30 P.M. with Registered Nurse (RN) #500 confirmed Resident #71 had PRN orders for butalbital-ASA-caffeine oral capsule and oxycodone HCI without parameters for the administration of the medications. RN #500 verified PRN pain medication orders should include parameters for the administration of the medication. 2. Review of the medical record for Resident #8 revealed an admission date of 12/08/25 with diagnoses including, but not limited to, cerebral infarction (stroke), cognitive communication deficit, localized edema, major depressive disorder, anxiety, and pain. Review of the MDS assessment, dated 12/12/25, revealed the resident had moderate cognitive impairment. Review of the care plan dated 12/15/25 revealed Resident #8 had complaints of pain related to osteoarthritis of the knee and rhabdomyolysis. Interventions included administering medications per orders, anticipate the resident's need for pain relief and respond immediately to any complaints of pain, assess for pain as ordered and as needed, and monitor for side effects of pain medications. Review of the physician orders revealed Resident #8 had an order dated 12/08/25 for Tylenol eight hour extended release (ER) 650 mg give two tablets every eight hours PRN for pain and an order dated 12/25/25 for tramadol 50 mg give one tablet twice daily PRN for pain. Neither order had parameters for the administration of the pain medications. Review of the MAR for December 2025 revealed Tylenol was given on the following dates: 12/09/25 for an assessed pain level of one, 12/17/25 for an assessed pain level of six, 12/18/25 twice for assessed pain levels of five and eight, 12/21/25 for an assessed pain level of five, and 12/24/25 for an assessed pain level of four. Further review revealed tramadol was given on the following dates: 12/27/25 twice for assessed pain levels of five and eight and 12/28/25 twice for assessed pain levels of eight and six. Review of the MAR for January 2026 revealed Tylenol was not administered through the survey date. Tramadol was administered on the following dates: 01/04/26 for an assessed pain level of eight, 01/11/26 for an assessed pain level of two, 01/12/26 twice for assessed pain levels of eight and five, and 01/13/26 for an assessed pain level of eight. Interview on 01/14/26 at 1:08 P.M. with the Director of Nursing (DON) verified there were no parameters to indicate when to administer Tylenol or tramadol to Resident #8. The DON confirmed parameters should be in place for PRN pain medication orders. Review of the facility policy titled, Administering Medications, dated April 2019, revealed the facility would administer medications in a safe manner.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on the review of the facility's Payroll-Based Journal (PBJ) Staffing Data Report, staffing schedule, posted daily staffing sheets, staff time sheets, and staff interview, the facility failed to submit accurate information in the PBJ in the third quarter of 2022. This had the potential to affect all residents. The facility census was 81. Findings Include: Review of the Payroll-Based Journal (PBJ) Staffing Data Report revealed the facility triggered for excessively low weekend staffing and not having licensed nursing coverage 24 hours a day in the third quarter of 2022. The specific days identified were Saturday 04/02/22, Sunday 04/03/22, Saturday 04/30/22, Saturday 05/14/22, Sunday 05/15/22, Saturday 06/11/22, and Saturday 06/25/22. Review of the Staffing Schedule and Posted Daily Staffing sheets for Saturday 04/02/22, Sunday 04/03/22, Saturday 04/30/22, Saturday 05/14/22, Sunday 05/15/22, Saturday 06/11/22, and Saturday 06/25/22 revealed the nursing staff worked 12 hour shifts, 7:00 A.M. to 7:30 P.M. and 7:00 P.M. to 7:30 A.M. On Saturday 04/02/22 there were four nurses working 7:00 A.M. to 7:30 P.M. and four nurses working in the facility from 7:00 P.M. to 7:30 A.M. On Sunday 04/03/22 there were four nurses working 7:00 A.M. to 7:30 P.M. and four nurses working in the facility from 7:00 P.M. to 7:30 A.M. On Saturday 04/30/22 there were four nurses working 7:00 A.M. to 7:30 P.M. and four nurses working in the facility from 7:00 P.M. to 7:30 A.M. On Saturday 05/14/22 there were four nurses working 7:00 A.M. to 7:30 P.M. and four nurses working in the facility from 7:00 P.M. to 7:30 A.M. On Sunday 05/15/22 there were four nurses working 7:00 A.M. to 7:30 P.M. and four nurses working in the facility from 7:00 P.M. to 7:30 A.M. On Saturday 06/11/22 there were four nurses working 7:00 A.M. to 7:30 P.M. and four nurses working in the facility from 7:00 P.M. to 7:30 A.M. On Saturday 06/25/22 there were four nurses working 7:00 A.M. to 7:30 P.M. and four nurses working in the facility from 7:00 P.M. to 7:30 A.M. The Staffing Schedules did not match the information entered into the PBJ as there was sufficient nurse staffing for 24 hours on each of the days identified as deficient in the PBJ. Reconciliation of the staff time sheets for Saturday 04/02/22, Sunday 04/03/22, Saturday 04/30/22, Saturday 05/14/22, Sunday 05/15/22, Saturday 06/11/22, and Saturday 06/25/22 verified the data on the Staffing Schedule and Posted Daily Staffing sheets were accurate. Interview on 10/25/23 at 10:53 A.M. with the Administrator verified the data entered into the PBJ for the third quarter of 2022 was not entered accurately. The Administrator reviewed the staffing schedule for each day indicated as not having sufficient 24 hour nursing staff and verified there were four nurses in the facility 24 hours a day on those days. The Administrator reported some of the shifts were split between two nurses but there were no gaps. The deficient practice was corrected on 06/01/23 when the facility implemented the following corrective action: On 06/01/23, new ownership assumed responsibility of the facility and implemented a new PBJ data reporting procedure. On 06/01/23, corporate support began staff data collection, review of facility staffing, and submission of data for the PBJ. Since the implementation of the new procedure, no additional concerns had been identified related to PBJ data reporting.

Based on resident funds account review and staff interview, the facility failed to ensure resident fund accounts were dispersed within 30 days of discharge from the facility. This affected one (#133) of one resident reviewed for conveyance of funds upon discharge. The facility census was 81. Findings Included: Review of Resident #133's medical record revealed an admitted [DATE]. The resident expired in the facility on [DATE]. Review of Resident #133's personal funds account revealed a copy of a check dated [DATE] made out to the resident's funeral home for $603.70. An additional check to the Treasurer of the State of Ohio was dated [DATE] in the amount of $654.29. Interview with Business Office Manager #476 on [DATE] at 1:28 P.M. verified Resident #133's remaining funds failed to be distributed timely. Interview with the Administrator on [DATE] at 2:15 P.M. verified the facility did not have a policy specific to resident funds but followed State regulations.

Based on record review, staff interview, and review of facility policy, the facility failed to ensure implementation of their abuse policy and obtain an employee background check was completed for State tested Nurse Aide (STNA) #432 prior to working with residents. This had the potential to affect 30 (#2, #4, #13, #14, #16, #18, #19, #20, #21, #24, #25, #27, #30, #31, #32, #35, #36, #38, #40, #42, #46, #47, #49, #54, #62, #63, #71, #74, #131, and #132) residents identified as residing on the 2 North Hallway in the facility and received care from STNA #432. The facility census was 81. Findings include: Review of State tested Nurse Aide (STNA) #432's personnel file revealed a hire date of 09/26/23. Further review revealed no evidence of the completion, or attempt to complete, a background check prior to employment. Review of the staffing schedules from 09/26/23 through 10/24/23 revealed STNA #432 was assigned to provide care to 30 (#2, #4, #13, #14, #16, #18, #19, #20, #21, #24, #25, #27, #30, #31, #32, #35, #36, #38, #40, #42, #46, #47, #49, #54, #62, #63, #71, #74, #131, and #132) residents on the 2 North Hallway during the night shift on 10/2/23, 10/4/23, 10/5/23, 10/9/23, 10/10/23, 10/13/23, 10/15/23, 10/18/23, 10/19/23, 10/23/23, and 10/24/23. Interview on 10/26/23 at 2:14 P.M. with Business Manager (BM) #476 confirmed the facility did not have STNA #432's background check. Follow-up interview on 10/26/23 at 3:40 P.M. with BM #476 revealed BM #476 called the sheriff's department and verified STNA #432 had not been in for a background check. Interview on 10/26/23 at 3:54 P.M. with the Administrator revealed she thought they had 30 days to get the background check completed and back to the facility. Review of facility policy titled Vancrest: Abuse: Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, undated, revealed it was the policy to undertake background checks of all employees and to retain on file applicable records of current employees regarding such checks. Additionally, the policy stated prior to hiring a new employee, the facility would conduct a criminal background check in accordance with Ohio law and Vancrest's policy;.

Based on record review, review of the facility self-reported incidents, staff interview, and review of the facility policy on abuse, the facility failed to ensure an allegation of physical abuse was reported to the state agency as required. This affected one (#55) of 19 residents screened for abuse. The facility census was 81. Findings include: Review of the medical record for Resident #55 revealed an admitted [DATE]. Medical diagnoses included cerebral infarction (stroke), vascular dementia, and depression. Resident #55 resided on the secured memory care unit. Review of the Minimum Data Set (MDS) quarterly assessment, dated 09/06/23, revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 04 which indicated severely impaired cognition. Resident #55 had no hallucinations, delusions, or behaviors. Resident #55 was coded to have adequate hearing with no hearing aid or other appliance used. The assessment further identified Resident #55 to need extensive assistance from one to two staff members for transferring, dressing, and personal hygiene. Review of the progress note dated 09/26/23 and timed 9:20 P.M. revealed an incident between Resident #55 and Agency State tested Nursing Assistant (STNA) #495. Resident #55 called out help me, and a staff STNA responded to take over care of Resident #55. The note described Resident #55 as fearful after Agency STNA #495 had began to start evening care without making Resident #55 aware of the plan. The progress note was authored by Licensed Practical Nurse #418 and was created on 09/27/23 at 10:33 A.M., thirteen hours after the event occurred. Interviews conducted on 10/25/23 between 6:20 A.M. and 7:24 A.M. with Licensed Practical Nurse (LPN) #418 revealed she was the night shift nurse for the memory care unit on 09/26/23. Agency STNA #495 worked in the memory care unit for a twelve hour shift with one other staff STNA. LPN #418 did not directly witness the event, but based her charting on the STNA's account of the event. LPN #418 stated she initially wrote a progress note that described the interaction between Resident #55 and Agency STNA #495 as an attack, but was called back in to the facility the next morning to meet with the Activities Director (AD) #479 and the Director of Nursing (DON), after which meeting she changed her documentation. LPN #418 stated she inactivated her original documentation and re-phrased her progress note. LPN #418 stated she did not directly notify a supervisor about the event that night, but may have mentioned it to the DON during a phone call about another situation. LPN #418 stated both she and the staff STNA she worked with that night provided a written statement. Review of Ohio Department of Health's Certification and Licensure System on 10/26/23 at 10:00 A.M. revealed no self-reported incident had been filed by the facility related to the allegation of physical abuse by Resident #55 on 09/26/23. Review of the daily staffing schedule, dated 09/26/23, revealed STNA #460 was mandated to work from 7:00 P.M. to 11:00 P.M. in the memory care unit with Agency STNA #495. An interview on 10/25/23 at 3:24 P.M. with STNA #460 revealed she works day shift from 7:00 A.M. to 7:00 P.M., but on 09/26/23 was mandated to work an additional four hours. STNA #460 stated 09/26/23 was the first time she had worked with Agency STNA #495. Agency STNA #495 entered Resident #55's room to provide care. STNA #460 walked down the hall when she heard Resident #55 yell help me. STNA #460 stated she knocked quickly but immediately entered the room and found Resident #55 with a hold on Agency STNA's arms. STNA #460 stated Resident #55 recognized her and asked you saw him attack me, right?. STNA #460 sent Agency STNA #495 out of the room and provided care to Resident #55. Resident #55 was upset, fearful, and continued to ask STNA #460 you saw him attack me, right. After care was completed for Resident #55, STNA #460 reported the event to LPN #418. STNA #460 stated she was called back in to the facility the next morning to discuss the incident and provide a written statement. Interview on 10/26/23 at 10:08 A.M. with the Administrator revealed she had no knowledge the incident with Resident #55 on 09/26/23. The Administrator verified she had not reported any self-reported incidents in September 2023, and confirmed the Administrator should be made aware of any and all abuse allegations and investigations of abuse. Interview on 10/26/23 at 10:15 A.M. with the DON and the Administrator revealed the DON was familiar with the incident. The DON stated she was aware of the situation, the facility had investigated the incident, and it was not an abuse situation. Interview on 10/26/23 at 10:35 A.M. with AD #479 revealed she also functioned as the Memory Support Manager and oversaw care of the residents who lived in the memory care unit. On 09/27/23, she saw LPN #418's progress note describing the event, and was concerned. AD#479 and the DON reached out to LPN #418 and STNA #460 and asked them to come in to discuss the situation. Both LPN #418 and STNA #460 provided a written statement. AD #479 stated there was no statement from Agency STNA #495, and the DON had the investigation in her office. AD #479 verified that Resident #55 had severely impaired cognition and a BIMS score of 04 seemed accurate for him. Interview on 10/26/23 at 11:02 A.M. with the DON revealed she discussed the incident with LPN #418 and STNA #460. The DON stated she asked LPN #418 to modify her statement, but figured she would add an addendum, not strike out and completely re-write the narrative. The DON provided a copy of the investigation which included two witness statements and two pages of printed-off progress notes from Resident #55's electronic medical record. The DON verified the four pages were the full investigation the facility completed. Review of witness statement authored by LPN #418, dated 09/27/23, referenced event that occurred 09/26/23 around 9:20 P.M. Agency STNA #495 went into Resident #495's room and did not ask for Resident #55's permission to perform care. Resident #55 yelled help, and STNA#460 entered the room. STNA #460 reported to LPN #418 that Agency STNA #495 attacked me. LPN #418 asked Resident #55 about the incident, and he reported he felt attacked and unsafe. LPN #418 asked Resident #55 why he felt that way, to which he stated Agency STNA #495 entered his room and just started touching and grabbing at him, and that the nurse needed to do something about him, referring to Agency STNA #495. The statement further indicated that LPN #418 asked Agency STNA #495 to not enter Resident #55's room the rest of the night and to communicate with residents before care was attempted. Review of witness statement authored by STNA #460, dated 09/27/23, revealed she entered Resident #55's room after she heard him call for help. Resident #55 was in bed, had a hold on Agency STNA #495's arm. Resident #55 recognized STNA #460 and stated she was his friend. STNA #460 took over the care of Resident #55 and asked him what had happened. Resident #55 asked if STNA #460 had seen Agency STNA #495 attack him. STNA #460 stated she had not witnessed anything firsthand. Resident #55 said nothing further other than he was glad STNA #460 was there. STNA #460 then reported the incident to the nurse. Interview on 10/26/23 at 12:28 with the Administrator and DON revealed the provided witness statements from LPN #418 and STNA #460 and the progress notes documented in Resident #55's medical record were the only components of the facility's investigative file for the incident. The Administrator and DON verified there had been no interviews or assessments attempted of like residents, no recent abuse education or in-servicing for staff, and Agency STNA #495 completed his twelve hour shift, and was not immediately removed from the patient care area. The Administrator indicated she had not read the two staff witness statements until 10/26/23 and verified both statements used the term attacked. Review of the policy Resident Rights, revised August 2022, revealed The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Employees shall treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of lift, recognizing each resident's individuality. The facility will protect and promote the rights of the resident. Review of the policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 2017, revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. It is the facility's policy to investigate all alleged violations involving abuse. Facility staff should immediately report all such allegations to the Administrator and to the Ohio Department of Health (ODH). If a staff member is accused or suspected of Abuse, they should immediately remove that staff member from the facility and the schedule pending the outcome of the investigation. The policy additionally notes that nursing home staff includes employees, consultants, contractors, volunteers, and any other caregivers who provide care and services to residents on behalf of the facility. Documentation in the nurses' notes should include the result of the resident's assessment, notification of the physician and the Resident Representative, and any treatment provided.

Based on record review, review of the facility self-reported incidents, staff interview, and review of the facility policy on abuse, the facility failed to conduct a thorogh investigation of alleged physical abuse. This affected one (#55) of 19 residents screened for abuse. The facility census was 81. Findings include: Review of the medical record for Resident #55 revealed an admitted [DATE]. Medical diagnoses included cerebral infarction (stroke), vascular dementia, and depression. Resident #55 resided on the secured memory care unit. Review of the Minimum Data Set (MDS) quarterly assessment, dated 09/06/23, revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 04 which indicated severely impaired cognition. Resident #55 had no hallucinations, delusions, or behaviors. Resident #55 was coded to have adequate hearing with no hearing aid or other appliance used. The assessment further identified Resident #55 to need extensive assistance from one to two staff members for transferring, dressing, and personal hygiene. Review of the progress note dated 09/26/23 and timed 9:20 P.M. revealed an incident between Resident #55 and Agency State tested Nursing Assistant (STNA) #495. Resident #55 called out help me, and a staff STNA responded to take over care of Resident #55. The note described Resident #55 as fearful after Agency STNA #495 had began to start evening care without making Resident #55 aware of the plan. The progress note was authored by Licensed Practical Nurse #418 and was created on 09/27/23 at 10:33 A.M., thirteen hours after the event occurred. Interviews conducted on 10/25/23 between 6:20 A.M. and 7:24 A.M. with Licensed Practical Nurse (LPN) #418 revealed she was the night shift nurse for the memory care unit on 09/26/23. Agency STNA #495 worked in the memory care unit for a twelve hour shift with one other staff STNA. LPN #418 did not directly witness the event, but based her charting on the STNA's account of the event. LPN #418 stated she initially wrote a progress note that described the interaction between Resident #55 and Agency STNA #495 as an attack, but was called back in to the facility the next morning to meet with the Activities Director (AD) #479 and the Director of Nursing (DON), after which meeting she changed her documentation. LPN #418 stated she inactivated her original documentation and re-phrased her progress note. LPN #418 stated she did not directly notify a supervisor about the event that night, but may have mentioned it to the DON during a phone call about another situation. LPN #418 stated both she and the staff STNA she worked with that night provided a written statement. Review of Ohio Department of Health's Certification and Licensure System on 10/26/23 at 10:00 A.M. revealed no self-reported incident had been filed by the facility related to the allegation of physical abuse by Resident #55 on 09/26/23. Review of the daily staffing schedule, dated 09/26/23, revealed STNA #460 was mandated to work from 7:00 P.M. to 11:00 P.M. in the memory care unit with Agency STNA #495. An interview on 10/25/23 at 3:24 P.M. with STNA #460 revealed she works day shift from 7:00 A.M. to 7:00 P.M., but on 09/26/23 was mandated to work an additional four hours. STNA #460 stated 09/26/23 was the first time she had worked with Agency STNA #495. Agency STNA #495 entered Resident #55's room to provide care. STNA #460 walked down the hall when she heard Resident #55 yell help me. STNA #460 stated she knocked quickly but immediately entered the room and found Resident #55 with a hold on Agency STNA's arms. STNA #460 stated Resident #55 recognized her and asked you saw him attack me, right?. STNA #460 sent Agency STNA #495 out of the room and provided care to Resident #55. Resident #55 was upset, fearful, and continued to ask STNA #460 you saw him attack me, right. After care was completed for Resident #55, STNA #460 reported the event to LPN #418. STNA #460 stated she was called back in to the facility the next morning to discuss the incident and provide a written statement. An interview on 10/26/23 at 10:08 A.M. with the Administrator revealed she had no knowledge the incident with Resident #55 on 09/26/23. The administrator verified she had not reported any self-reported incidents in September 2023, but the Administrator should be made aware of any and all abuse allegations and investigations of abuse. An interview on 10/26/23 at 10:15 A.M. with the DON and the Administrator revealed the DON was familiar with the incident. The DON stated she was aware of the situation, the facility had investigated the incident, and it was not an abuse situation. An interview on 10/26/23 at 10:35 with AD #479 revealed she also functions as the Memory Support Manager and oversaw care of the residents who lived in the memory care unit. On 09/27/23, she saw LPN #418's progress note describing the event, and was concerned. AD#479 and the DON reached out to LPN #418 and STNA #460 and asked them to come in to discuss the situation. Both LPN #418 and STNA #460 provided a written statement. AD #479 stated there was no statement from Agency STNA #495, and the DON had the investigation in her office. AD #479 verified that Resident #55 had severely impaired cognition and a BIMS score of 04 seemed accurate for him. An interview on 10/26/23 at 11:02 A.M. with the DON revealed she discussed the incident with LPN #418 and STNA #460. The DON stated she asked LPN #418 to modify her statement, but figured she would add an addendum, not strike out and completely re-write the narrative. The DON provided a copy of the investigation which included two witness statements and two pages of printed-off progress notes from Resident #55's electronic medical record. The DON verified the four pages were the full investigation the facility completed. Review of witness statement authored by LPN #418, dated 09/27/23, referenced event that occurred 09/26/23 around 9:20 P.M. Agency STNA #495 went into Resident #495's room and did not ask for Resident #55's permission to perform care. Resident #55 yelled help, and STNA#460 entered the room. STNA #460 reported to LPN #418 that Agency STNA #495 attacked me. LPN #418 asked Resident #55 about the incident, and he reported he felt attacked and unsafe. LPN #418 asked Resident #55 why he felt that way, to which he stated Agency STNA #495 entered his room and just started touching and grabbing at him, and that the nurse needed to do something about him, referring to Agency STNA #495. The statement further indicated that LPN #418 asked Agency STNA #495 to not enter Resident #55's room the rest of the night and to communicate with residents before care was attempted. Review of witness statement authored by STNA #460, dated 09/27/23, revealed she entered Resident #55's room after she heard him call for help. Resident #55 was in bed, had a hold on Agency STNA #495's arm. Resident #55 recognized STNA #460 and stated she was his friend. STNA #460 took over the care of Resident #55 and asked him what had happened. Resident #55 asked if STNA #460 had seen Agency STNA #495 attack him. STNA #460 stated she had not witnessed anything firsthand. Resident #55 said nothing further other than he was glad STNA #460 was there. STNA #460 then reported the incident to the nurse. An interview on 10/26/23 at 12:28 with the Administrator and DON revealed the provided witness statements from LPN #418 and STNA #460 and the progress notes documented in Resident #55's medical record were the only components of the facility's investigative file for the incident. The Administrator and DON verified there had been no interviews or assessments attempted of like residents, no recent abuse education or in-servicing for staff, and Agency STNA #495 completed his twelve hour shift, and was not immediately removed from the patient care area. The Administrator indicated she had not read the two staff witness statements until 10/26/23 and verified both statements used the term attacked. Review of the policy Resident Rights, revised August 2022, revealed The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Employees shall treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of lift, recognizing each resident's individuality. The facility will protect and promote the rights of the resident. Review of the policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 2017, revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. It is the facility's policy to investigate all alleged violations involving abuse. Facility staff should immediately report all such allegations to the Administrator and to the Ohio Department of Health (ODH). If a staff member is accused or suspected of Abuse, they should immediately remove that staff member from the facility and the schedule pending the outcome of the investigation. The policy additionally notes that nursing home staff includes employees, consultants, contractors, volunteers, and any other caregivers who provide care and services to residents on behalf of the facility. Documentation in the nurses' notes should include the result of the resident's assessment, notification of the physician and the Resident Representative, and any treatment provided.

Based on medical record review, staff interview, and review of facility policy, the facility failed to implement appropriate fall interventions for Resident #69. This affected one (#69) of two residents reviewed for falls. The facility census was 81. Findings include: Review of the medical record for Resident #69 revealed an admitted [DATE]. Medical diagnoses included dementia, anxiety, osteoarthritis, and closed left hip fracture with surgical repair. Resident #69 resided on the secured memory care unit. Review of the Minimum Data Set (MDS) quarterly assessment, dated 09/01/23 revealed Resident #69 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated severely impaired cognition. Resident #69 required extensive assistance of one to two staff members with activities of daily living (ADLs). Review of the plan of care, initiated 09/24/21, revealed Resident #69 to be at high risk for falls and injury due to arthritis, dementia, cardiac disease, confusion, incontinence, poor balance and safety awareness and an unsteady gait. The care plan was updated on 07/14/23 and indicated Resident #69 sustained a left hip fracture and was sent to the hospital on 07/13/23. Review of Resident #69's Fall Risk Assessment, dated 07/13/23, revealed a score of a 13. Review of the Fall Risk Assessment, dated 09/23/23, revealed a score of 16. Each assessment score indicated Resident #69 was at high risk for falls. Review of interdisciplinary progress notes revealed Resident #69 had falls at the facility on 07/13/23, 08/03/23, 09/21/23 and 09/23/23. The documentation did not identify interventions placed to prevent fall reoccurrence. Further review revealed no documented falls in the year prior to the fall on 07/13/23. Review of the Nurse Root Cause Analysis form, dated 07/13/23 and timed 6:40 A.M., completed by Licensed Practical Nurse (LPN) #418, revealed Resident #69 was found on the floor lying on her left side in front of her wheelchair. Resident #69 was in pain and was transferred to the local hospital for evaluation. There was no intervention listed on the root cause analysis form with a statement of there has been no implementations, I suggest a fall mat and a pendant. Review of Resident #69's hospital records dated 07/13/23 and 07/14/23 revealed Resident #69 sustained a closed left hip fracture as a result of a fall that occurred at the facility on 07/13/23. Resident #69 had her hip surgically repaired at the hospital on 07/13/23 and returned to the facility on [DATE]. Review of the Nurse Root Cause Analysis form, dated 08/03/23 and timed 3:15 P.M., completed by LPN #415, revealed Resident #69 sustained a fall in her bathroom after an attempted self-transfer. Resident #69 was not injured. The listed intervention was to encourage Resident #69 to use her call light. Review of the Nurse Root Cause Analysis form, dated 09/21/23 and timed 6:50 P.M., completed by Registered Nurse (RN) #405, revealed Resident #69 was observed on the floor in the lounge area seated on her buttocks. Resident #69 was not injured. There was no listed intervention implemented to prevent future fall occurrences. Review of the Nurse Root Cause Analysis form, dated 09/23/23 and timed 9:45 A.M., completed by LPN #412, revealed Resident #69 sustained a fall when she was attempting to transfer from wheelchair to bed, but the wheelchair brakes were not locked. Resident #69 was observed on the ground near her bed and wheelchair. Resident #69 was not injured. The listed intervention was to reinforce the need for Resident #69 to use her call light for assistance. Interview on 10/24/23 at 4:44 P.M. with LPN #411 revealed Resident #69 was independently mobile in her wheelchair, confused, and extremely forgetful. Interview on 10/26/23 at 10:35 A.M. with Activities Director (AD) #479 revealed she also functioned as the Memory Support Manager and oversaw care of the residents who lived in the memory care unit. AD #479 stated the nurse on duty should have assessed Resident #69 after each fall, completed the notifications to the provider and responsible party, completed the incident report and implemented a fall intervention. AD #479 stated she then gave completed fall reports to the Director of Nursing (DON). Falls were routinely discussed in morning meeting where the root cause was identified. AD #479 stated all falls should have an intervention placed to prevent fall recurrence. AD #479 verified Resident #69 had severely impaired cognition and education on the use of a call light would not be appropriate or effective. AD #479 verified the fall reports dated 07/13/23 and 09/21/23 listed no intervention and that fall reports dated 08/03/23 and 09/23/23 listed an inappropriate and ineffective intervention. Interview on 10/26/23 at 11:11 A.M. with the Director of Nursing (DON) verified Resident #69 had impaired cognition. The DON verified no interventions were placed for Resident #69 following falls sustained on 07/13/23 and 09/21/23. The DON stated the fall interventions placed following falls on 08/03/23 and 09/23/23 of reminders or education for Resident #69 to utilize her call light to call for assistance were not appropriate for her cognition. Review of the policy Fall Risk Assessment Policy and Incident and Accident Reporting, revised 10/01/14, revealed a Fall Risk Assessment with a score of 10 or greater indicates the resident is at high risk for falls and appropriate interventions should be put into place. Additionally, an immediate intervention to prevent reoccurrence must be instituted for all falls.

Based on staff interview, medical record review, and review of facility policy, the facility failed to ensure the pharmacy recommendations were completed on a monthly basis and were timely addressed by the physician. This affected one (Resident #34) of five reviewed for unnecessary medications. The facility census was 81. Findings include: Review of the medical record for Resident #34 revealed an admitted [DATE]. Medical diagnoses included cerebral infarction (stroke) affecting left non-dominant side, vascular dementia, and insomnia. Resident #34 resided in the secured memory care unit. Review of the Minimum Data Set (MDS) quarterly assessment, dated 08/10/23, revealed a Brief Interview for Mental Status (BIMS) of 00, indicating severely impaired cognition. The resident was noted to have verbal behaviors directed towards others and other behavioral symptoms not directed towards others on one to three days during the seven-day lookback period. Resident #34 required extensive assistance of one to two staff members for activities of daily living (ADLs). Resident #34 was identified to have received antipsychotic medications on a routine basis during the seven-day lookback period. Review of consultant pharmacist recommendations revealed no evidence that a medication regimen review was completed by the consultant pharmacist in April 2023. Additionally, the facility was unable to locate the recommendation completed by the consultant pharmacist dated 05/23/23. An interview on 10/25/23 at 3:43 P.M. with the Director of Nursing (DON) verified she was unable to locate the physician-signed pharmacy recommendation sheet from 05/23/23 for Resident #34. Follow-up interview on 10/26/23 at 11:02 A.M. with the DON verified there was no evidence of a medication regimen review completed in April 2023. The DON verified there was no evidence of a medication regimen review conducted between 03/01/23 and 05/23/23. Additionally, the DON stated she was still unable to locate the physician-signed pharmacy recommendation sheet from 05/23/23 and it was unknown what recommendation was made. The DON stated the facility had three different pharmacies over the past year and believed that was where the breakdown occurred. Review of the policy titled Medication Regimen Reviews, revised May 2019, revealed the consultant pharmacist performs a medication regimen review for every resident in the facility receiving medication. Medication regimen reviews are done upon admission and at least monthly thereafter, or more frequently if indicated. The consultant pharmacist provides the director of nursing services and medical director with a written, signed and dated copy of all medication regimen reports. Copies of medication regimen reports, including physician responses, are maintained as part of the permanent medical record.

Based on staff interview, medical record review, and review of facility policy, the facility failed to ensure an as needed medication order for a psychotropic medication was limited to a 14 day duration and instructions for use were followed. This affected one (Resident #61) of five reviewed for unnecessary medications. The facility census was 81. Findings include: Review of the medical record for Resident #61 revealed an admitted [DATE]. Medical diagnoses included Alzheimer's disease, depression, cognitive communication deficit, and anxiety. Resident #61 resided on the secured memory care unit. Review of Resident #61's Minimum Data Set (MDS) admission assessment, dated 08/09/23, revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. Resident #61 required extensive assistance of one to two staff members for activities of daily living (ADLs). Review of Resident#61's physician's order, dated 09/19/23 revealed a medication order for Lorazepam (Ativan, an anti-anxiety medication) 0.25 milligrams (mg) by mouth twice daily routinely for anxiety. Review of Resident #61's physician's order, dated 09/19/23, revealed an as needed medication order, for Ativan 0.25 mg by mouth as needed for anxiety at 2 P.M. The order was open-ended with no end date listed. Review of Resident #61's Medication Administration Record (MAR) for September 2023 revealed Resident #61 received an as needed dose of Ativan on 09/22/23 at 5:00 A.M. An interview on 10/26/23 at 12:40 P.M. with the Director of Nursing (DON) verified Resident #61's open-ended as needed Ativan order and stated the order should be limited to 14 days duration. The DON verified the dose administered to Resident #61 on 09/22/23 at 5:00 A.M. was not given within the order parameters and should not have been administered. Review of the policy Tapering Medications and Gradual Dose Reductions, Revised July 2022, revealed the staff and practitioner shall seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences.

Based only record review, observation, interview, review and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to resume communal dining as per CMS and CDC guidelines. This had the potential to affect all residents of the facility with the exception of one (Resident #5) who received no food by mouth and three (Residents #25, #108, #420) who are on transmission-based precautions and isolated to their rooms. The facility census was 113. Findings include: Review of the CDC COVID-19 county positivity rate dated 06/28/21 revealed Wyandot county had a positivity rate of 2.2 percent. During observation on 06/28/21 at 11:38 A.M., the main dining room on the first floor had ten residents, seated one resident per table. No residents were observed seated together. During observation on 06/28/21 from 11:53 A.M. to 12:32 P.M., the second floor dining room had eight residents, seated one resident per table. No residents were observed seated together. During observation on 06/29/21 at 12:00 P.M., Resident #4 was eating lunch in her room. During interview on 06/29/21 at 2:36 P.M., State tested Nursing Assistant (STNA) #602 stated Resident #4 has been eating in her room. The resident used to eat in the dining room with other residents, but since the facility is only allowing one resident per table, she now prefers to eat in her room. STNA stated the resident enjoyed sitting with other residents. STNA stated she believed all but one resident on the floor is vaccinated. During observation on 06/30/21 at 11:37 A.M., the first floor dining room revealed residents eating at separate individual tables for social distancing. During interview on 06/30/21 at 12:16 P.M., STNA #604 stated residents eat at separate individual tables for social distancing. During interview on 07/01/21 at 10:32 A.M., Residents #114, #36, #99, #71, #2, #66, and #88 stated they were not allowed to sit together in the dining room during meals. Residents #114 and #71 reported they had tried to sit together for meals on multiple occasions and staff tell them they need to separate. Review of the CDC website titled Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 vaccination dated 04/27/21 revealed, fully vaccinated residents can participate in communal dining without use of source control or physical distancing. Unvaccinated residents in communal area should use source control when not eating and unvaccinated residents should continue to remain at least six feet from others.

Based on observation, interview, record review and policy review, the facility failed to ensure residents were served the correct altered texture diet. This affected two (Residents #9 and #102) of two residents reviewed for altered diets. The facility census was 113. Findings include: 1. Review of the Minimum Data Set (MDS) assessment for Resident #9, dated 03/31/21 revealed the resident required total dependence for eating with one person physical assistance, was cognitively impaired and rarely understood. The resident's diet order was a regular diet, pureed texture, nectar consistency. 2. Review of the MDS assessment for Resident #102, dated 05/31/21, revealed the resident required extensive assistance of one person for eating, was cognitively impaired and rarely understood. The resident's diet order was a regular diet, blended texture, thin consistency. 3. During observation on 06/28/21 between 12:24 P.M. and 12:32 P.M. Resident #102 was served Resident #9's meal tray and Resident #9 was served Resident #102's meal tray. Resident #102 had a tray with pureed roast beef, mashed potatoes, carrots, pudding, chocolate magic cup and thickened cranberry juice. The meal ticket had Resident #9's name printed on the top. Resident #9 had a tray with pureed roast beef, mashed potatoes, carrots, pudding, magic cup (thickened nutritional supplement ice cream) and ensure plus (nutritional supplement drink) and thinned juice. The meal ticket had Resident #102's name printed at the top. Both residents were ordered a pureed texture diet, however Resident #9 was supposed to have nectar thickened liquids and Resident #102 was supposed to have thin liquids. Resident #102 received Resident #9's thickened liquids and Resident #9 received Resident #102's thin liquids. State tested Nursing Assistant (STNA) #616 was observed feeding Resident #9's meal to Resident #102, including Resident #9's thickened liquids. Registered Nurse (RN) #614 was assisting Resident #9 with eating Resident #102's meal. RN #614 offered thinned juice to Resident #9. Resident #9 proceeded to drink the thinned juice. During interview on 06/28/21 at 12:32 P.M., STNA #616 reported it was her second day and she was unaware of which resident she was assisting. She identified Resident #102 by reviewing the resident's sock label. STNA #616 verified Resident #102 was served and being fed Resident #9's meal, but it was okay because both residents had the same diet. STNA #616 did not attempt to stop feeding Resident #102, even after realizing she was feeding Resident #102 the wrong meal tray. RN #614 verified Resident #102 and Resident #9 were served each other's meal trays. RN #614 further verified Resident #102 received and consumed Resident #9's thickened juice and Resident #9 received and consumed Resident #102's thinned juice. Review of facility policy titled Therapeutic Diets, revised 12/11/19 revealed the facility had a policy in place for assuring a resident receives and consumes foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment, plan of care, in accordance with his/her goals and preferences.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident was provided the appropriate antibiotic to treat a urinary tract infection [MEDICAL CONDITION]. This caused actual harm to Resident #67 when she was treated with an antibiotic for a UTI which was not sensitive to the infective organism. This led to the resident being hospitalized for [REDACTED]. This affected one (#67) of one residents reviewed for UTI. Additionally, the facility failed to proper store catheter supplies to prevent possible contamination for one (#72) of one resident reviewed out of five identified with an indwelling urinary catheter. The facility census was 133. Findings include: 1. Review of Resident #67's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment, dated 01/04/19, identified the resident as having severe cognitive impairment. It identified the resident as requiring total dependence of one person with bed mobility; personal hygiene, and dressing, total dependence of two persons with transfers and toilet use, and supervision with eating. Review of Resident #67's nurses' notes revealed on 02/08/19 at 1:58 P.M. the resident was very sleepy during the shift. On 02/08/19 at 4:51 P.M. the residents's blood pressure was 157/85, pulse was 98 per minute, respirations were 20 per minute, and temperature was 99 degrees Fahrenheit (F). The resident's daughter was insisting on a urinalysis. The nurse explained facility protocol and the daughter stated the resident can't tell you if there is something wrong. The on call Certified Nurse Practitioner (CNP) was contacted regarding the resident's condition and new orders obtained. Review of the physician orders on 02/08/19 at 4:53 P.M. revealed there was a new order obtained for a urine culture. Review of the nurses' notes on 03/08/19 at 5:15 P.M. revealed Resident #67 was straight catheterized for the urine specimen, which was sent to the lab. The nurses notes on 02/08/19 at 7:00 P.M. revealed the urinalysis results were: cloudy, moderate blood, large amount of leukocytes, and 3+ bacteria. The CNP was notified and a new order was obtained. Review of the physician orders on 02/08/19 at 7:39 P.M. revealed a new order was obtained for the antibiotic [MEDICATION NAME] 500 milligrams (mg) one tablet by mouth two times a day for seven days for a urinary tract infection. Review of the microbiology report dated 02/11/19 at 9:31 A.M. revealed the resident had >100,000 gram positive cocci. The organism was [MEDICATION NAME] faecalis. The sensitivity revealed the organism was susceptible to the antibiotics [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME]. [MEDICATION NAME] was not listed as an antibiotic the organism was susceptible to. This lab was signed and dated by the CNP on 02/22/19. Review of the physician order dated 02/11/19 at 12:15 P.M. revealed to continue [MEDICATION NAME]. Review of a nurses' note on 02/11/19 at 3:00 P.M. revealed the physician was aware of the urinalysis culture and sensitivity (C&S) results which were greater than 100,000 gram positive cocci with the organism [MEDICATION NAME] faecalis. The CNP noted to continue the current antibiotic of [MEDICATION NAME]. Review of the CNP progress note dated 02/11/19 revealed the on-call nurse practitioner was notified of the patient and orders for urinalysis were received after staff reported patient had been having increased fatigue. Results of the urinalysis and culture came back. The patient was placed on Cetin. It indicated the patient will continue with Cetin through the entire course of therapy with an end date of 02/15/19. Review of a nurses' notes on 02/22/19 at 1:30 P.M. revealed the resident had an emesis and a temperature of 100.3 degrees F, blood pressure was 162/80, pulse was 88 per minute, and respirations were 16 per minute. The resident's color was ashen and she was lethargic. Review of the physician orders revealed a complete blood count (CBC), comprehensive metabolic panel (CMP), a urinalysis with culture and sensivity, and an abdominal x-ray were ordered. Additionally, the anti-nausea medication [MEDICATION NAME] was ordered every six hours as needed for nausea and vomiting. A clear liquid diet for 24 hours and then progress was noted. Review of the nurses' note on 02/22/19 at 3:13 P.M. revealed Resident #67's family was present and would like the resident to be sent to the emergency room (ER) and a new order was obtained to send the resident to the ER. A nurses' note on 02/26/19 at 5:00 P.M. revealed the resident was readmitted to the facility at 4:41 P.M. Review of the CNP progress note dated 02/22/19 revealed the staff had reported the resident developed onset of nausea and vomiting. Stated the patient has been recognized to have a fever of 100.3 degrees F. State tested Nurse Aide (STNA) reports the patient has not been acting right since this morning. It revealed the resident had been treated recently for a urinary tract infection. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Review of the Hospitalist history and physical dated 02/22/19 revealed two weeks ago the resident had a urinary tract infection that was treated with [MEDICATION NAME], which was not sensitive to the organism or at least it was not tested , and she now has decreased mental status and has been admitted through the ER as a septic patient. The assessment and plan plan [MEDICAL CONDITION] probably from UTI. Interview with the Director of Nursing (DON) on 03/20/19 at 9:32 A.M. confirmed the culture and sensitivity report was shown to CNP #500. She confirmed [MEDICATION NAME] was not a sensitive antibiotic, however, he said to continue it. The DON voiced the [MEDICATION NAME] was continued since the CNP ordered it after it was verified the [MEDICATION NAME] was what the CNP wanted to keep. Interview with the CNP #500 on 03/20/19 at 12:20 P.M. confirmed the resident had a urine culture collected which came back positive for an infection with the resident started on [MEDICATION NAME] by the on call CNP. CNP #500 stated on 02/11/19 at 12:15 P.M. he had written a physician orders to continue the [MEDICATION NAME], however, at the time the order was written he was not aware of the culture and sensitivity results. He confirmed on 02/22/19 he had signed off on the resident's urine culture and sensitivity report and confirmed [MEDICATION NAME] was not a sensitive antibiotic. Until the culture and sensitivity was completed and reviewed the [MEDICATION NAME] was a good choice for antibiotics, however, after the sensitivity had came back the antibiotic should have been changed to something different that would have been more appropriate for the sensitivity. He confirmed per the culture and sensitivity results [MEDICATION NAME] was not a susceptible antibiotic. Interview with Registered Nurse (RN) #111 on 03/20/19 at 3:32 P.M. voiced the laboratory results for Resident #67, including the culture and sensitivity results, were in the CNP #500's box. When CNP #500 was done reviewing them he turned them over and put them on the desk. She voiced she had thought CNP #500 had looked at all of the laboratory results, however, she did not know until after the resident was in the hospital that he did not initial the culture and sensitivity results. RN #11 state she did not call and tell CNP #500 about the results of the culture and sensitivity results. Review of the facility policy titled Antibiotic Stewardship Policy and Procedure, dated 09/08/17, revealed the infection preventionist will be responsible to lead the committee and to conduct monitoring and reporting, improve clinical outcomes and minimize adverse outcomes related to antibiotic use. The procedure indicated to promote best practices reflecting Centers for Medicare Services Core Measures and Center for Disease Control guidelines regarding use of appropriate antibiotics and to evaluate and promote the use of lab testing procedures needed for the rapid identification of pathogens; discourage the use of outdated, redundant and/or unnecessary lab testing procedures related to infectious diseases and antibiotic use. 2. Review of Resident #72's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #72's Minimum Data Set (MDS) assessment, dated 01/10/19, listed the resident as having an indwelling catheter. Review of Resident #72's monthly physician orders, dated (MONTH) 2019, revealed an order to change Foley catheter once monthly. Observation on 03/19/19 at 1:43 P.M. of Resident #72's bathroom revealed a urinary catheter bag with a small amount of urine in it hanging uncovered on a towel bar. A urine collection device was also observed sitting on the back of the toilet and was uncovered. Observation on 03/20/19 at 9:18 A.M. of Resident #72's bathroom revealed a urinary catheter bag with a small amount of urine in it hanging uncovered on a towel bar. Interview on 03/19/19 at 3:00 P.M. with Licensed Practical Nurse (LPN) #207 verified Resident #72's contaminated urinary catheter bag and urine collection device should not be uncovered.