Every finding on record at Villa Georgetown Rehabilitation and Healthcare Cen

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, family interview, staff interview, review of the facility therapy to nursing communication form and review of facility policy, the facility failed to provide adequate staff assistance during transfers to prevent falls. This resulted in actual harm on 01/15/25 at approximately 12:25 P.M. to Resident #100 when Certified Nursing Assistant (CNA) #20 completed a hands-on transfer of the resident from the wheelchair to the bed without the assistance of additional staff. Resident #100 sustained a fall to the floor during the transfer, resulting in a left femur fracture. This affected one resident (#100) of three residents reviewed for falls. The facility census was 84. Findings include: Review of the medical record for Resident #100 revealed an admitted [DATE]. Diagnoses included cerebral infarction (stroke), spastic hemiplegia (causes muscle tightness and involuntary contractions on one side of the body), diabetes mellitus, epilepsy, seizures, depression, anxiety, foot drop (difficulty lifting the front part of the foot), and hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #100 revealed no information for this resident due to the length of stay in the facility. Review of the care plan, dated 01/14/25, revealed Resident #100 had an activities of daily living (ADLs) self-performance deficit and required staff assistance related to hemiplegia, foot drop, cerebral infarction, and overall medical condition. Interventions included total staff dependence with transfers and the resident required the assistance of one or more staff with transfers. Review of the facility Therapy to Nursing Communication Form, dated 01/14/25 and completed by Physical Therapy Assistant (PTA) #40, revealed Resident #100 had left-sided hemiplegia due to a previous cerebral infarction and was evaluated to need two staff assistance for all transfers. Further review revealed Licensed Practical Nurse (LPN) #10 acknowledged the communication on 01/14/25. Review of a nursing progress note, dated 01/15/25 at 12:35 P.M., revealed LPN #30 immediately responded to the room of Resident #100 after hearing her screaming in pain. Upon arrival, she witnessed CNA #20 and Resident #100 both on the floor, after an attempted transfer. Further review revealed Resident #100 was screaming in excruciating left hip pain. LPN #30 documented she was unable to complete an assessment due to the position of both CNA #20 and Resident #100. In addition, the note documented Resident #100 stated that during the transfer, both of their legs (Resident #100 and CNA #20) had gotten tangled, causing them both to fall to the floor. Review of a nursing progress note, dated 01/15/25 at 4:25 P.M., revealed Resident #100's father reported to LPN #30 via telephone correspondence that the resident had a fractured left hip and would be awaiting an orthopedic consultation at the hospital. Review of the Fall Investigation note for Resident #100, dated 01/16/25, revealed Resident #100 had a fall with major injury related to staff assisting the resident and both falling to the floor when the resident's legs became entangled with CNA #20. It further stated the resident's left lower extremity range of motion was abnormal, as she was unable to move it due to extreme pain. Review of CNA #20's written statement, dated 01/16/25, revealed Resident #100 wanted to get into her bed from her wheelchair. Their legs became tangled during the transfer, which caused both of them to fall. Interview on 02/22/25 at 8:24 A.M. with Resident #100's family member revealed the resident sustained a fractured left hip, requiring the placement of a metal rod in her left leg, as a result of the fall on 01/15/25. He further added that the resident transferred to another facility following her hospitalization . A telephone interview on 02/22/25 at 10:40 A.M. with CNA #20 revealed she was seven months pregnant at the time of the incident with Resident #100. CNA #20 stated she was informed Resident #100 was a one-person staff assist for transfers, but did not confirm this information. CNA #20 stated during Resident #100's transfer, their legs become entangled, causing both of them to fall to the floor. She verified she was the only staff member in the room at the time of the fall and further confirmed Resident #100 began screaming in pain after the fall to the floor. CNA #20 denied knowledge of the therapy communication form, completed on 01/14/25, which indicated Resident #100 was to be a two-person staff assist with transfers. An interview on 02/22/25 at 11:50 A.M. with LPN #30 revealed she had responded to Resident #100's room on 01/15/25 when she heard the resident screaming in pain. LPN #30 verified Resident #100 had fallen after CNA #20 attempted to transfer her alone. An interview on 02/22/25 at 12:10 P.M. with the Director of Nursing (DON) confirmed the therapy communication form completed on 01/14/25 indicated Resident #100 required two-person staff assistance with transfers due to her medical conditions. The DON verified Resident #100's fall occurred after this assessment had been completed and acknowledged by LPN #10 and only one staff (CNA #20) assisted with the resident's transfer at the time of the fall on 01/15/25. The DON further confirmed the facility received report from the father of Resident #100 on 01/15/25 that the resident's left hip was fractured and required surgical intervention. The DON revealed the facility did not have hospital records related to the incident because the resident did not return to the facility. Review of the facility policy titled, Falls, dated September 2021, revealed, based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Review of the undated facility policy titled, Activities of Daily Living (ADLs), revealed appropriate care and services would be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with mobility (transfer and ambulation). The deficiency was corrected on 02/17/25 when the facility implemented the following corrective actions: On 01/15/25 at approximately 12:25 P.M., LPN #30 assessed Resident #100, who was noted with pain and abnormal range of motion (ROM). Resident #100 was transferred to the hospital for further evaluation and treatment. On 01/15/25, the DON or designee updated Resident #100's plan of care to include assistance of two-staff with transfers. On 01/15/25, the DON or designee re-assessed Resident #100's fall risk and determined the resident remained at low risk for falls. On 01/15/25, the DON or designee educated all licensed nursing staff on ensuring communication between therapy and matched the resident's care plan and Kardex (system for organizing resident information). Review of the nursing in-service sign in sheets confirmed the education was provided. On 01/21/25, the DON or designee reviewed the therapy evaluations for all residents to ensure the level of assistance recommended by the therapy department matched the resident's care plan and Kardex. No discrepancies were identified. Beginning on 01/24/25, the DON or designee will audit four residents weekly for four weeks to ensure therapy recommendations for assistance with transfers were communicated to the nursing department and matched the resident's care plan and Kardex. The audits will be reviewed weekly by the Quality Assurance and Performance Improvement (QAPI) committee for trends and recommendations. Telephone interview on 02/25/25 at 12:00 P.M. with LPN #10, LPN #110, and Registered Nurse (RN) #100 confirmed the facility provided mandatory education on ensuring therapy recommendations were properly communicated and documented. In addition, education was provided on proper transfers and utilizing the required staff assistance level identified for each resident. Review of the facility audits from 01/24/25 through 02/17/25 revealed there were no further concerns identified. Review of two (#12 and #74) additional open resident records revealed no related concerns. This deficiency represents non-compliance investigated under Complaint Number OH00162046.

Based on medical record review, observation, interviews, and staff interview. the facility failed to ensure care and services were implemented to prevent worsening of contractures. This affected one (Resident #53) of four facility-identified residents with contractures. The facility census was 73 residents. Findings include: Review of the medical record for Resident #53 revealed an admitted [DATE] with diagnoses including hemiplegia, dysarthria, and respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #53 dated 05/13/24revealed the resident had mildly impaired cognition and had functional limitation in range of motion to one side of the upper extremities. Review of the active care plans for Resident #53 revealed there was no plan of care developed for contractures or splint/orthotic use. Review of the active physician's orders for Resident #53 revealed there were no orders for the application or removal of splints/orthotics. Review of the occupational therapy (OT) discharge summary for Resident #53 dated 05/02/24 revealed the discharge recommendations included the resident should use a right resting hand orthotic as tolerated. Observations on 06/24/24 at 1:17 P.M. and on 06/26/24 at 9:00 A.M. revealed Resident #53's right hand was contracted and there was no splint or other orthotic device in place. Interview on 06/27/24 at 10:40 A.M. with the Director of Nursing (DON) confirmed Resident #53's right hand was contracted and there had no physician orders or care plan initiated regarding the use of a right resting hand orthotic for the resident as recommended per OT.

Based on medical record review and staff interview the facility failed to ensure resident Pre-Admission Screening and Resident Review (PASARR) documents were accurate regarding resident current conditions and diagnoses. This affected two (Residents #2 and #45) of three residents reviewed for PASARR documents. The facility census was 73 residents. Findings include: Review of the medical record for Resident #2 revealed an admitted [DATE] with diagnoses including psychotic disorder with delusions, dementia without behaviors, major depressive disorder, and hypertension. Review of the PASARR for Resident #2 dated 10/17/11 revealed it did not include the diagnosis of psychotic disorder recorded on the document. Review of the annual Minimum Data Set (MDS) assessment for Resident #2 dated 06/04/24 revealed the resident was severely cognitively impaired, used a wheelchair to aid in mobility, and was always incontinent of bowel and bladder. Interview on 06/27/24 at 10:25 A.M with Director of Business Development (DOB) #142 confirmed Resident #2's PASARR did not include the resident's admitting diagnosis of psychotic disorder was not included and the PASARR needed to be updated. 2. Review of the medical record for Resident #45 revealed an admitted [DATE] with diagnoses including cerebral infarction due to unspecified occlusion, type two diabetes mellitus with hyperglycemia, schizoaffective disorder bipolar type (added 11/11/22), dementia without behaviors, senile degeneration of brain, and anxiety disorder (added 01/19/21). Review of the PASARR for Resident #45 dated 01/24/22 revealed it did not include the diagnoses of schizoaffective disorder or anxiety disorder. Review of the quarterly MDS assessment for Resident #45 dated 04/01/24 revealed the resident was cognitively intact, used a wheelchair and walker to aid in mobility, and was frequently incontinent of bladder and always continent of bowel. Interview on 06/27/24 at 10:25 A.M with DOB #142 confirmed Resident #2's PASARR did not include the resident's diagnoses of schizoaffective disorder, and anxiety disorder and needed to be updated.

Based on record review, observation, staff interview, review of the facility policy, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess the resident's skin, failed to timely identify a resident's pressure ulcer until it reached an advanced stage, and failed to ensure pressure ulcer prevention interventions were in place. This resulted in Actual Harm to Resident #67 who was at risk for pressure ulcers and the facility found Resident #67's pressure ulcer as an unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar) to her coccyx and did not accurately assess the wound upon identification of the wound. This affected two (Residents #59 and #67) of three residents reviewed for pressure ulcers. The facility identified seven residents with pressure ulcers. The facility census was 81. Findings include: 1) Review of the medical record for Resident #67 revealed an admitted [DATE]. Diagnoses included pancreatitis, congestive heart failure (CHF), heart disease, atrial fibrillation, and major depressive disorder. Review of the care plan dated 12/20/22 revealed Resident #67 was at risk for impaired skin integrity related to edema, confined to a chair all or most of the time, impaired cognition, incontinent of bladder, incontinent of bowel, and slides down in bed. Interventions included the following: dietary supplement(s) as ordered, encourage good nutrition and hydration, assist as needed, encourage the resident to reposition self if able, notify physician of any new areas of impaired skin integrity, and a pressure reduction mattress to bed. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs). Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #67 was at risk for the development of pressure ulcers. Review of the medical record revealed there were no skin issues identified until 02/03/23. The nursing progress note dated 02/03/23 revealed Resident #67 had a new wound to her coccyx which the nurse classified as a stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough). The wound evaluation for Resident #67 dated 02/03/23 revealed the pressure ulcer to the resident's coccyx was 100% covered in slough and measured 1.0 cm in length by 0.6 cm in width by 0.2 cm in depth. The progress note did not classify the pressure ulcer correctly due to the wound evaluation stated there was 100% slough present in the wound. Review of the physician's orders dated 02/03/23 revealed to cleanse the wound with normal saline, pat dry, apply thin layer of Medihoney. Apply calcium alginate (cut to fit wound bed). Cover with foam dressing on day shift every other day. Review of the wound NP note for Resident #67 dated 02/07/23 revealed the pressure ulcer to the resident's coccyx was classified as an unstageable pressure ulcer and measured 1.0 cm in length by 1.6 cm in width by 0.4 cm in depth with a moderate amount of drainage and 100% slough to the wound bed. NP orders included to offload resident's heels per the facility protocol. The wound NP changed the treatment to cleanse the coccyx wound with a wound cleanser, pat dry, apply triad to wound bed and cover with foam dressing. Change daily on day shift and as needed. Review of the wound NP note for Resident #67 dated 02/28/23 revealed the unstageable pressure ulcer to resident's coccyx measured 1.6 cm in length by 1.1 cm in width by 0.5 cm in depth with a moderate amount of serosanguineous drainage noted which has no odor. The wound bed had 51-75% slough. Wound NP gave order again to offload heels per facility protocol. Observation on 03/06/23 at 9:41 A.M. revealed Resident #67 was resting on a pressure reduction mattress. Resident #67's heels were resting directly on the mattress and were not floated. Interview on 03/06/23 at 9:41 A.M. with Registered Nurse (RN) #545 confirmed Resident #67 had a pressure ulcer to her coccyx and she did not have any orders to float her heels or use any type of devices such as heel boots to relieve pressure to her heels. Interview on 03/06/23 at 2:38 P.M. with LPN #680 confirmed the nurse who identified the wound for Resident #67 had not correctly classified the wound when she called it a stage II pressure ulcer. LPN #680 confirmed the wound NP classified the wound as unstageable because of the presence of slough in the wound bed which was noted in the nurse's assessment on 02/03/23. LPN #680 further confirmed the wound for Resident #67 was not identified until it had reached an advanced stage. LPN #680 confirmed the resident was at risk for breakdown to her heels and her heels should be offloaded as recommended by the wound NP. LPN #680 confirmed Resident #67 had no orders to offload heels or use devices such as heel boots. Interview on 03/06/23 at 3:00 P.M. with the Director of Nursing (DON) confirmed Resident #67 did not have orders to offload heels, but she was at risk for further skin breakdown and should have interventions in place. The DON confirmed staff should inspect skin regularly during care and wounds should be identified before they reach an advanced stage. 2) Review of the medical record for Resident #59 revealed an admitted [DATE]. Diagnoses included protein calorie malnutrition, diabetes mellitus (DM), fracture of right femur, atherosclerotic heart disease, and acute kidney failure. Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #59 was at high risk for the development of pressure ulcers. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADLs.) Resident #59 was coded as at risk for pressure ulcers and was coded for the presence of an unstageable pressure ulcer which was not present on admission. Review of the nurse progress note dated 12/31/22 revealed Resident #59 had a new pressure ulcer to the left heel. The nurse notified the nurse practitioner (NP) and initiated a treatment per standing orders. Review of the wound evaluation for Resident #59 dated 12/31/22 revealed the pressure ulcer to the resident's left heel measured five centimeters (cm) in length by 4.5 cm in width. The wound had no depth and no drainage. The nurse placed the wound evaluation in the facility wound care nurse's folder. The nurse classified the wound as a stage I pressure ulcer (skin is intact with red or discolored area). Review of the wound evaluation for Resident #59 dated 01/04/23 revealed the facility's wound care nurse, Licensed Practical Nurse (LPN) #680, assessed Resident #59's left heel wound. The resident's left heel measured 7.5 cm in length by 4.5 cm in width. LPN #680 classified the wound as a diabetic ulcer. Review of the wound NP note dated 01/05/23 revealed Resident #59 had a deep tissue injury (DTI) ulcer (Purple or [NAME] area of discolored intact skin due to damage of underlying soft tissue) to her left heel which measured 5.0 cm in length by 3.4 cm in width with no measurable depth. The wound was non-blanchable with deep red, maroon, and purple discoloration. Wound NP gave new orders for wound care which included to cleanse the wound with wound cleanser, pat dry, apply Betadine, and cover with border foam dressing once daily, offload heels per facility protocol. Review of the care plan, last updated 02/14/23, revealed Resident #59 had impaired skin integrity as evidenced by: pressure ulcer to the left heel related to confinement to a chair all or most of the time, impaired cognition, incontinent of bladder, incontinent of bowel, needs assistance with ADLs. Interventions included the following: assist the resident with turning and repositioning every two hours and as needed, skin inspection every seven days, notify nurse of any new areas of skin breakdown noted during bathing or daily care, notify physician or NP of noted worsening skin condition or any new areas of skin breakdown, float heels when in bed, and to have cushioned heel boots to bilateral feet. Review of the wound NP note for Resident #59 dated 02/28/23 revealed the wound to the left heel was now classified a stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed.) which measured 2.2 cm in length by 0.9 cm in width by 0.3 cm in depth. There was a moderate amount of serosanguinous drainage noted which had no odor. The wound bed had 26-50 percent (%) slough. Wound NP gave order again to offload heels per facility protocol. Review of the monthly physician orders for March 2023 revealed Resident #59 had an order to float heels when in bed dated 06/17/22 and an order dated 06/24/22 for Resident #59 to have cushioned heel boots to bilateral feet. Review of the March 2023 Treatment Administration Record (TAR) for Resident #59 revealed the orders to float heels and wear cushioned heel boots were not included in TAR. Observation and interview on 03/06/23 at 9:45 A.M. with LPN #680 revealed Resident #59 was resting on a pressure reduction mattress. There was a dressing in place to the resident's left heel dated 03/05/23. Resident's heels were resting directly on the mattress and were not floated. LPN #680 confirmed Resident #59 had a stage III pressure ulcer to her left heel and the resident's left heel was resting directly on the mattress. LPN #680 confirmed Resident #59 was supposed to wear soft heel boots when she was in bed, and she wasn't sure why they were not in place. Observation of wound care with LPN #680 on 03/06/23 at 11:08 A.M. revealed Resident #59's heels were not floated. Resident #59 had a dime sized open wound to the left heel which had visible slough in the wound bed. Interview on 03/06/23 at 11:20 A.M. with LPN #680 confirmed Resident #59's heels were not floated. LPN #680 again confirmed Resident #59 was supposed to be wearing heel boots, but she couldn't find them. Interview on 03/06/23 at 2:38 P.M. with LPN #680 confirmed she first saw Resident #59's wound on 01/04/23 and it looked like a large purple fluid filled blister and she classified it as a diabetic ulcer. LPN #680 confirmed she was with the wound NP on 01/05/23 when the wound was reclassified as a deep tissue injury (DTI.) Interview on 03/06/23 at 3:00 P.M. with the Director of Nursing (DON) confirmed Resident #59 should be wearing heel boots or have her heels floated on pillows while in bed. Review of the undated facility's policy titled Pressure Reducing and Relieving Devices revealed the facility would implement appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. Review of the facility's undated policy titled Skin and Wound Program Best Practice revealed the facility would ensure staff conduct a head to toe inspection of resident's skin every seven to 10 days. Review of the NPUAP guidelines dated 2014 pages 70-71 at https://npiap.com/general/custom.asp?page=2014Guidelines revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Ongoing assessment of the skin was necessary to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. Review of the NPUAP guidelines dated 2014 page 115 revealed ideally, heels should be free of all pressure, a state sometimes called floating heels. Pressure can be relieved by elevating the lower leg and calf from the mattress by placing a pillow under the lower legs, or by using a heel suspension device that floats the heel. Consequently, the pressure will instead spread to the lower legs, and the heels will no longer be subjected to pressure. This deficiency represents non-compliance investigated under Complaint Number OH00140190.

Based on personnel file review, review of the Ohio Department of Health (ODH) Nurse Aide Registry, staff interview and policy review, the facility failed to ensure all State tested Nursing Assistants (STNA's) providing direct care to residents had a current and up to date Nurse Aide Registry. This affected two (#95 and #125) out of three STNA personnel files reviewed and had the potential to affect all 77 residents residing at the facility. Facility census was 77. Findings include: Review of the personnel files and review of the ODH Nurse Aide Registry (https://nurseaideregistry.odh.ohio.gov/Public/PublicNurseAideSearch) for STNA #95, and #125 revealed their nurse aide registration information had not been updated and both of their registries were expired. STNA #95's Nurse Aide Registry was noted to have expired on [DATE] and STNA #125's Nurse Aide Registry was noted to have expired on [DATE]. Interview on [DATE] at 1:00 P.M. with the Administrator and Assisted Director of Nursing (ADON) #159 revealed the facility has about 60 STNA's and as far as they are aware all the STNA's have a current Nurse Aide Registry. Interview on [DATE] at 2:30 P.M. with Payroll/Human Resource (HR) #25 revealed after looking at her Nurse Aide Registry, she noticed there were two STNA's (#125 and #95) who were not listed on this list and she went ahead and immediately send the information over to the correct agency to report their hours worked and education completed to maintain their Nurse Aide Registry. Review of these letters that were sent to the Nurse Aide Registry revealed there were errors on the documents with the personal information for STNA #125 and #95. Review of the facility policy titled Licensure, Certification, and Registration of Personnel, no dated noted, revealed employees who require a license, certification, or registration to perform their duties must present verification with their application of employment. A copy of the current licensure, certification, or registration number must be filed in the employee's personnel record. This deficiency substantiates Complaint Number OH 200.

Based on observations, staff interviews, and record review, the facility failed to maintain laundry dryers in a safe manner and prevent a build up of dryer lint in the facility dryers. This had the potential to affect all 81 residents who resided in the facility. Findings include: Observation on 07/22/21 at 11:28 A.M. of Dryer #2 lint screen revealed lint hanging from the lint screen and balled up in the base of the dryer. Interview on 07/22/21 at 11:28 A.M. with Laundry #58 confirmed the lint had built up in the dryer. Laundry #58 stated the dryers were cleaned tree times a day of dryer lint. Observation on 07/22/21 at 11:40 A.M. with Maintenance Director #500 revealed a build up of lint in Dryer #1 with lint collected in soccer size balls under Dryer #1. Interview on 07/22/21 at 11:40 A.M. with the Maintenance Director #500 verified the large amount of lint collected until Dryer #1. He stated the lint trap should be cleaned after every three loads and stated the new linens the facility received gave off more lint than older linens. Review of the laundry staff lint trap signed out sheet revealed the staff signed once a day for dryer lint trap clean out. There was a noted on the sign out sheet stating the staff were to clean the dryer lint traps after every three loads.

Based on record review, review of the facility's policy, and resident and staff interviews, the facility failed to develop and implement care plans to address dental care, hospice care, and fluid restrictions. This affected five (#4, #8, #36, #42, and #46) of 19 residents reviewed for care planning. The facility census was 81. Findings include: 1. Medical record review for Resident #36 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #36's progress note, dated 04/06/21, revealed Resident #36 had seen the dentist briefly, but resident stated he was planning to discharge back to the community, and he wanted to see his own dentist. Review of Resident #36's annual Minimum Data Set (MDS) assessment, dated 06/09/21, revealed the resident was cognitively intact and required supervision with personal hygiene. Resident #36 was reported to have obvious or likely cavities or broken natural teeth. Review of Resident #36's care plan, dated 07/20/21, revealed the resident did not have a dental care plan. Interview with Resident #36 on 07/19/21 revealed he needed his top teeth pulled. Interview with Social Services (SS) #7 on 07/21/21 at 8:34 A.M. revealed Resident #36 refused dental services on 04/06/21 due to resident planning to discharge. Interview with the Director of Nursing (DON) on 07/22/21 at 8:26 A.M. verified Resident #36 did not have a dental care plan prior to 07/22/21. 2. Review of the medical record for the Resident #8 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) 3.0 assessment, dated 02/01/21, revealed the resident was cognitively intact. Review of the physician orders, dated 10/26/20, revealed Resident #8 had a fluid restriction of 2,000 milliliter (ml.) total in 24 hours every shift for CHF which included 1,080 ml. for dietary, and 920 ml. for nursing departments. Review of the care plan, dated 05/04/21, revealed Resident #8 had altered cardiovascular status hypertension, CHF, CKD, and anxiety. Resident #8 was on diuretic therapy related to hypertension and CHF. Interventions included to administer diuretics as ordered and monitor for side effects and effectiveness, and gradual dose changes as needed. Resident #8 had altered nutrition and hydration related to hypertension, chronic [CONDITION(S)], arthritis, [CONDITION(S)], pneumonia, chronic respiratory failure, asthma, [CONDITION(S)], history of significant weight changes. Family brought outside food and resident was not complaint with diet. Interventions included diet as ordered, snacks/supplements as ordered, honor food/fluid preferences, monitor weight as ordered, notify the physician (MD) of significant weight changes, labs as ordered. There was no mention of the resident's fluid restriction in the care plans developed for Resident #8. 3. Medical record review for Resident #42 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment, dated 06/19/21, revealed Resident #42 had moderately impaired cognition. Review of the care plan initiated on 03/03/20 revealed Resident #42 had CHF, [CONDITION(S)], history of [CONDITION(S)], [CONDITION(S)], and hypertension. Interventions included to check breath sounds, monitor for labored breathing, encourage adequate nutrition, give cardiac medications as ordered, monitor vital signs, monitor/document signs of malnutrition, and monitor/document/report signs and symptoms of CHF. There was no mention of the resident's fluid restriction in the care plans developed for Resident #42. Review of the physician orders, dated 09/22/20, revealed Resident #42 had a fluid restriction for 2,000 ml. total in 24 hours related to unspecified heart failure which included 1,080 ml. for dietary, and 920 ml. for nursing departments. 4. Medical record review for Resident #46 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment, dated 06/27/21, revealed Resident #46 was cognitively intact. Review of the care plan, dated 03/18/19, revealed Resident #46 had altered cardiovascular status related to hypertension, CKD, CHF, and [CONDITION(S)]. Interventions included to administer medications as per order, assess for chest pain, encourage low salt/low fat diet, monitor and report abnormal vital signs/lung sounds, and educate resident/family regarding nature of disease and risk factors. There was no mention of the resident's fluid restriction in the care plans developed for Resident #46. Review of the physician orders, dated 06/30/20, revealed Resident #46 had a fluid restriction on 1,800 ml. total in 24 hours which included 960 ml. for dietary and 840 ml. for nursing departments. Interview on 07/20/2021 at 7:30 A.M. Registered Nurse (RN) #19 stated fluid restrictions were typically included in the dietary care plan which was updated by the dietician. RN #19 verified Resident #46, #42 and #8 had no interventions listed in the care plan which mentioned fluid restriction prior to the annual survey dated 07/19/21. The RN confirmed revisions were made to Resident #8s care plan for CHF on 07/19/21 for fluid restriction including history of resident non-compliance. On 07/20/21, RN #19 revised Resident #42 and #46's care plan to include fluid restriction interventions. 5. Record review for Resident #4 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/19/21, revealed the resident had intact cognition. Review of the physicians' order for Resident #4, dated 03/19/21, revealed an order to admit the resident to hospice services. Review of the comprehensive care plan, last reviewed on 05/17/21, revealed no care plan for hospice services were in place. Interview on 07/22/21 at 10:20 A.M. with Registered Nurse (RN) #119 verified there was not an active hospice care plan in place for Resident #4. Review of the facility's policy titled Care Plan Documentation Guidelines, dated 2005, revealed staff developed a coordinated plan to provide appropriate care for each problem identified.

Based on medical record review, resident interview, and staff interview, the facility failed to ensure the resident was invited to her care plan conference meetings to provide input to her plan of care. This affected one (#32) of three residents reviewed for participation in care planning. The facility census was 81. Findings include: Review of the medical record revealed Resident #32 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was her own responsible party. Review of the annual Minimum Data Set (MDS) assessment, dated 06/07/21, revealed the resident had no impaired cognition for decisions. Record review revealed Resident #32 has not been offered to attend care conference meeting within the past 12 months. Interview on 07/19/21 at 2:10 P.M. with Resident #32 reported not attending a care plan meeting once since she was admitted and nothing after that. Interview on 07/21/21 at 9:33 A.M. with Director of Social Services (DSS) #7 stated before COVID-19, the facility mailed out invitations at the end of the month. Invitations were documented in the interdisciplinary (IDT) meetings. DSS #7 reported care conferences were probably not documented. DSS #7 verified no documentation of Resident #32 being invited to care conferences and denied having any letters for care plan meetings for Resident #32. Interview on 07/21/21 at 2:30 P.M., the Director of Nursing (DON) verified care conference was held for Resident #24 on 09/07/20 but unable to verify Resident #32's invitation or participation. DON denied having any documentation of attendance sheet or a letter inviting Resident #32 to care plan meetings in the past year. DON referred surveyor back to DSS #7.

Based on observation, medical record review, and staff interview, the facility failed to ensure a revision was made to a resident' care plan for falls. This affected one (#53) of 19 residents reviewed for care plans. The facility census was 81. Findings include: Medical record review for Resident #53 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review the annual Minimum Data Set (MDS) assessment, dated 07/01/21, revealed the resident was cognitively intact. Review of the care plan, dated 12/11/20, revealed the resident was at high risk for falls related to muscle weakness, diabetes, depression, [CONDITION(S)], [CONDITION(S)], and chronic pain. Interventions included for staff to ensure the resident has slipper socks on when in bed, a floor mat by her bed, and non-skid socks always when not wearing shoes. Observations on 07/20/21 at 2:15 P.M. and on 07/21/21 at 1:15 P.M. revealed Resident #53 was in bed and had no fall mat in place and no non-skid socks on feet Observation on 07/21/21 at 1:24 P.M., revealed Licensed Practical Nurse (LPN) #78 and State tested Nursing Aide (STNA) #108 witnessed Resident #53 getting out of bed with no non-skid socks on and no fall mat in place. The staff verified the findings. After surveyor intervention, STNA #108 took off the socks and placed non-skid socks on Resident #53. Interview on 07/21/21 at 1:25 P.M. with LPN #78 reported Resident #53's floor mat was supposed to be taken off the care plan due to the resident was self-ambulating out of bed without calling for assistance. LPN #78 reported Resident #53 was non-compliant with taking off her non-skid socks. Interview on 07/21/21 at 2:02 P.M. with Registered Nurse (RN) #19 reported Resident #53 was non-compliant with taking socks off or changing them while in bed. RN #19 was unable to provide a care plan for non-compliant with non-skid socks. RN #19 verified the care plan needed revised.

Based on record review, observation, and resident and staff interviews, the facility failed to provide activities of daily living (ADL) for for residents who were dependent on staff for their care. This affected three (#16, #39, and #277) of seven residents reviewed for ADLs. The facility census was 81 residents. Findings include: 1. Record review for Resident #39 revealed the resident was readmitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the ADL plan of care, dated 01/09/21, revealed the resident was a two-person physical assistance for bathing. Review of the five-day Minimum Data Set (MDS) assessment, dated 07/14/21, revealed the resident had severely impaired cognition and required an extensive assistance of one staff person for bathing. Review of the facility's bath record for Resident #39 revealed a shower was given on 07/14/21 since readmission on 07/09/21. The resident had not received any other bath or shower from 07/09/21 to 07/18/21. Observations on 07/19/21 at 2:29 P.M. revealed Resident #39 had greasy and stringy hair. The resident was unable to state when the last bath had been given. Interview with the Director of Nursing (DON) on 07/22/21 at 12:00 P.M. confirmed Resident #39 received one shower since readmission on 07/09/21. 2. Review of Resident #16's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the revised care plan, dated 11/22/19, revealed there were oral/dental health problems related to full dependency of oral care, poor salivary moistening/cleaning of mouth teeth, and lips. Interventions include for staff to routinely complete mouth inspections during shifts and provide care. Review of the Dental Summary Report for 360 care, dated 04/06/21, revealed Resident #21 was seen in his room, plague heavy, gingivitis and occlusal ware. The dentist requested for daily mouth care if possible. Resident #16 was to be brought to the dental clinic at the next visit. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/10/21, revealed Resident #39 was moderately impaired and was total dependent on activity of daily living with one-person physical assist for dental/oral care. Review of Resident #16's electronic record from 07/01/21 to 07/20/21 revealed personal hygiene ,which also included brushing of the teeth were not completed on every shift. There were no documented initials on shifts from 2:00 P.M. to 10:00 P.M. for 07/01/21, 07/02/21, 07/04/21, 07/05/21, 07/06/21, 07/08/21, 07/12/21, 07/13/21, 07/14/21, 07/16/21, 07/17/21, 07/19/21, 07/20/21, and 07/21/21. For the shift 10:00 P.M. to 6:00 A.M. for 07/02/21, 07/05/21, 07/06/21, 07/07/21, 07/08/21, 07/10/21, 07/11/21, 07/13/21, 07/14/21, 07/16/21, 07/17/21, 07/19/21 and 07/20/21. Observations on 07/21/21 at 11:00 A.M. and on 07/22/21 at 10:15 A.M. revealed the resident was sleeping. His mouth was opened and his teeth had an abundance of white substance layered on them. Interview on 07/21/21 at 12:33 P.M. with State tested Nursing Aide (STNA) #59 explained how to read the shower sheets and personal hygiene sheets. STNA #59 stated if there were no initials next to the residents' name them a shower or personal hygiene care was not given, but if there were initials next to resident's name then they received a shower that day. Interview on 07/22/21 at 10:30 A.M. with Licensed Practical Nurse (LPN) #66 reported the resident received her shower last night and her teeth were brushed. LPN #66 reported STNAs and nurses brush Resident #16's teeth three to four times a day. Observation on 07/22/21 at 10:35 A.M., revealed Resident #16's mouth was opened and his teeth had an abundance of white substance layered on them. On 07/22/21 at 11:45 A.M. with the Director of Nursing (DON) verified the findings with no initials on the personal hygiene sheet. 3. Review of the medical record for Resident #277 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/10/20, revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Resident #277 was a two-person physical assist and required extensive assistance for bathing. Review of the care plan, dated 09/10/21, revealed Resident #277 had a self-care deficit related to [CONDITION(S)], [CONDITION(S)], spinal stenosis, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], hypertension, and coronary artery disease. Interventions included two-person assistance with bathing. Review of the task documentation, dated September 2020, revealed Resident #277 received one shower on 09/18/20 during her stay at the facility from 09/10/20 to 09/18/20. The facility did not provide paper shower sheets dated from 09/10/20 to 09/18/20. Interview on 07/20/21 at 3:55 P.M. with State tested Nurse Aide (STNA) #59 verified there was one shower documented for Resident #277 on 09/18/2020 for her entire stay at the facility from 09/10/20 to 09/18/20. STNA #59 stated the residents were scheduled to receive two showers per week, and showers were assigned according to room and bed location. STNA #59 stated the showers were always documented under the shower task and were specified not to be documented in the personal hygiene task. This deficiency substantiates Complaint Numbers OH 930, OH 775, OH 560, and OH 010.

Based on observation, record review and staff interviews, the facility failed ensure resident oxygen tubing was changed per the physician orders. This affected two (#12 and #35) of three residents reviewed for respiratory care. The facility identified 15 residents who utilized oxygen. The facility census was 81. Findings include: 1. Medical record review revealed Resident #35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/08/21, revealed the resident was moderately cognitively impaired. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR), dated July 2021, revealed Resident #35 was ordered to change his oxygen tubing weekly every night shift, every Thursday. Resident #35 had his oxygen tubing changed on 07/08/21 and 07/15/21 according to the TAR. Observation of Resident #35's oxygen tubing on 07/19/21 at 10:10 A.M. revealed the oxygen tubing to be dated 07/08/21. Subsequent observation of Resident #35's oxygen tubing on 07/21/21 at 2:43 P.M. revealed the oxygen tubing to be dated 07/08/21. Interview with the Director of Nursing (DON) on 07/21/21 at 2:43 P.M. verified Resident #35's oxygen tubing to be dated 07/08/21. 2. Record review for Resident #12 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment, dated 05/01/21, revealed the resident had intact cognition. Review of the physicians' order, dated 10/06/20, revealed an order to change oxygen tubing every seven days on night shift and to initial and date all tubing. Observation on 07/19/21 at 9:10 A.M. of the oxygen tubing connected to the concentrator of Resident #12 revealed the tubing had a piece of tape which contained the date of 07/08/21 and no initials. The tubing was placed in the nose of Resident #12 and was on delivering oxygen. Interview with Registered Nurse (RN) #63 on 07/19/21 at 9:10 A.M. verified the oxygen tubing for Resident #12 contained the date of 07/08/21 and was not initialed.

Based on staff interview, employee record review, and review of facility's job description, the facility failed to ensure the Activity Director was a qualified activity professional to direct the provision of activities to the residents. This had the potential to affect all 81 residents residing in the facility. Findings include: Review of the employee record for the Activity Director (AD) #34 revealed her date of hire was 06/01/20. There were no qualifications of an activity director in her employee record. Interview on 07/22/21 at 08:46 A.M. with AD #34 revealed she did not have her certification as an Activity Director or meet the education requirements to be a certified Activity Director of a nursing facility. AD #34 stated she was currently enrolled in an activity director course and plans to finish the course by October 2021. Interview on 07/22/21 at 02:00 P.M. with the Human Resource Manager (HRM) #16 confirmed the facility does not have a certified Activity Director at the facility. Review of the facility's job description titled Job Description: Activity Director, dated April 2021, confirmed the Activities Director must be certified (or willing to obtain certification within six months of employment).

Based on observation, medical record review, staff interview, review of the facility's policy and review of the information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure timely treatments, interventions, and assessments were done for a resident's pressure ulcers. This resulted in actual harm when Resident #226's pressure ulcers to his bilateral heels and sacrum deteriorated in condition and increased in size from the delay in treatment. This affected one (Resident #226) of two residents reviewed for pressure ulcers. The facility identified three residents with pressure ulcers. The facility census was 70. Findings include: Review of the medical record for Resident #226 revealed a re-admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the nursing re-admission assessment, dated 03/05/20, revealed Resident #226 had two stage one pressure ulcers (intact skin with non-blanchable redness of a localized area) to the left and right buttocks and three unstageable pressure areas (full thickness tissue loss in which the base of the ulcer is covered by slough or eschar in the wound bed) to the left great toe and to the left and right heels. Review of the wound assessment, dated 03/05/20, revealed Resident #226 had an unstageable area to the left great toe upon re-admission described as reddened with no drainage and measured 1.2 centimeters (cm.) in length by 0.6 cm. in width. The resident had an unstageable area to her right heel described as dry with no drainage and measured 3.0 cm. in length by 1.4 cm. in width and had an unstageable area to her left heel described as dry with no drainage and measured 3.0 cm. in length by 2.0 cm. in width. The resident had a stage two pressure ulcer to his left buttock described as pink and dry with no drainage and measured 1.0 cm. in length by 0.6 cm. in width and 0.2 cm. in depth. There was a reddened area surrounding to her buttocks measuring 9.0 cm. by 2.0 cm. Review of the physician orders, dated March 2020, revealed on 03/05/20, there were orders to turn every two hours, house barrier ointment after each incontinent episode, and [MEDICATION NAME] skin barrier to buttocks every shift for the pressure ulcer. On 03/06/20, there were orders to float the heels when in bed and a low air loss mattress for wound management when authorization approved. On 03/10/20, there were new orders for a low air loss mattress to the bed and to monitor both heels and apply skin prep every shift and leave open to air. There were no treatments for the heels upon readmission until five days later, on 03/10/20 and there were no treatments for the area to the left great toe. Review of the admission Minimum Data Set (MDS) assessment, dated 03/09/20, revealed Resident #226 had moderate cognitive deficits, had presence of stage two pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, and may present as an intact or open/ruptured blister) and two deep tissue injuries (classified as purple or maroon area of discolored intact skin due to damage of underlying soft tissue) that were all present upon readmission. The MDS assessment showed the resident had deteriorated to two stage two pressure ulcers versus the readmission nursing assessment and the initial wound assessment on 03/05/20, which stated two stage one pressure ulcers. Review of the treatment administration record (TAR), dated March 2020, revealed the nurses were not documenting any treatments or monitoring of any wound areas until 03/10/20. On 03/10/20, the nurse began to monitor both heels and apply skin prep every shift and began treatment of [REDACTED]. On 03/11/20, the nurse began to monitor the area to the left big toe and applied skin prep every shift for wound healing. Review of the certified nurse practitioner note, dated 03/10/20, revealed Resident #226 was admitted back to the facility with ulcerations to the bilateral heels and excoriation to the sacrum. He had unstageable areas to the left and right heels and a rash to the sacrum. There was no mention of an area to the left great toe. Review of the wound assessment, dated 03/10/20, revealed Resident #226 had unstageable area to the right heel described as necrotic tissue and black in color with measurements of 2.5 cm. in length by 4.5 cm. in width. The width had increased in size since the last measurement on 03/05/20 and now it was necrotic. The unstageable area to the left heel was described as necrotic and black in color and measured 3.0 cm. in length by 5.0 cm. width. The width was larger from 3.0 cm. on 03/05/20 and now was necrotic. The stage two pressure ulcer to the sacrum now had 25 percent slough to the wound bed. There were no measurements for the area to the left great toe. Observations on 03/10/20 at 9:47 A.M., at 3:32 P.M., and 5:51 P.M. of Resident #226 revealed he was resting in bed with his eyes closed. He had his feet laying directly on the bed and not elevated and there were no pillows to the foot of the bed or on the floor beside the bed. Interview and observation on 03/10/20 at 5:51 P.M. with Registered Nurse (RN) #130 verified Resident #226 did not have his feet elevated off his bed. He stated he may have kicked his pillows off. Observation of his heels with RN #130 revealed they were dark purple in color and his left great toe was reddish purple in color. He was laying on his bottom and there was no observation of his sacrum wound was done at this time. RN #130 stated he had just been in earlier to assess him and he needed to get him a different treatment and better positioning. Interview on 03/12/20 at 2:08 P.M. with the Director of Nursing (DON) stated Resident #226 had been sent out to the hospital that morning due to complications from his trach. He verified the treatments for his bilateral heels were not started until 03/10/20 because they were just to keep them elevated prior to the initiation of treatment because they were 'reabsorbing'. He verified there was no further documentation, treatment or assessment for the pressure ulcer to the left great toe stating he was under the understanding it was 'reabsorbing'. He verified the wound measurements for the pressure ulcers to his bilateral heels and sacrum had grown bigger and deteriorated in condition. He stated the nurse may have documented wrong upon admission because he was not a certified wound nurse. He verified the wound assessments for the bilateral heels were done on 03/10/20 and revealed they were necrotic, and the sacrum wound had the presence of slough. He stated he was seen by nurse practitioner on 03/10/20. Review of the facility's undated policy titled Best Practice Guidelines Skin Management Process Policy revealed residents identified having active skin issues will have a routine assessment and interdisciplinary team review and care plan implemented to maintain and or improve skin integrity. Review of the information from the NPUAP revealed a deep tissue pressure injury is intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage Three or Stage Four). Do not use deep tissue pressure injury to describe vascular, traumatic, neuropathic, or dermatologic conditions. Further review of the NPUAP revealed staff should assess pressure points, such as the sacrum, coccyx, buttocks, heels, ischium, trochanters, elbows and beneath medical devices, implement interventions to ensure that the heels are free from the bed and use heel offloading devices or [MEDICATION NAME] foam dressings on individuals at high-risk for heel ulcers.

Based on medical record review and staff interview, the facility failed to timely respond to monthly pharmacy recommendations. This affected two (#74 and #75) of five residents reviewed for pharmacy recommendations. Facility census was 70. Findings include: 1. Record review of Resident #74 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the 02/25/20 quarterly Minimum Data Set (MDS) revealed Resident #74 was cognitively intact and required total dependence for bed mobility, transfer, and toilet use, She required extensive assistance for personal hygiene, dressing and locomotion off unit. Review of the 12/13/19 Monthly Pharmacy Review revealed Resident #74 was prescribed [MEDICATION NAME] (an antiemetic drug) for treatment of [REDACTED]. The form was not seen by the physician until 02/26/20. and agreed to discontinue the medication. 2. Record review of Resident #75 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the the 01/27/20 quarterly MDS revealed the Resident #75 was severely cognitively impaired and required extensive assistance for bed mobility, transfer, dressing, personal hygiene and toilet use. Review of 12/13/19 Monthly Pharmacy Review revealed the Resident was due for a semi annual [MEDICATION NAME] (antidepressant) gradual dose reduction. The physician did not answer the recommendation until 02/26/20. Interview with the Director of Nursing (DON) on 03/12/20 at 10:27 A.M. verified the pharmacy recommendation for Resident #74 and #75 dated 12/13/19 was not addressed until with the physician until 02/26/20.

Based on medical record review, staff interview, and facilities policy review, the facility failed to update and revise a resident's care plans. This affected one (Resident #226) of 20 residents reviewed for care plan accuracy. The facility census was 70. Findings include: Review of the medical record for Resident #226 revealed a re-admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the nursing re-admission assessment, dated 03/05/20, revealed Resident #226 had two stage one pressure ulcers to the left and right buttock (intact skin with non-blanchable redness of a localized area), and three unstageable pressure areas (full thickness tissue loss in which the base of the ulcer is covered by slough or eschar in the wound bed) to the left great toe and to the left and right heels. Review of the wound assessment, dated 03/05/20, revealed Resident #226 had an unstageable area to the left great toe, an unstageable area to her right heel and had a stage two pressure ulcer to his left buttock. There was a reddened area surrounding to her buttocks measuring 9.0 cm. by 2.0 cm. Review of the admission Minimum Data Set (MDS) assessment, dated 03/09/20, revealed Resident #226 had moderate cognitive deficits, had presence of stage two pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, and may present as an intact or open/ruptured blister) and two deep tissue injuries (classified as purple or maroon area of discolored intact skin due to damage of underlying soft tissue) that were all present upon readmission. The MDS assessment showed the resident had deteriorated to two stage two pressure ulcers vs. the readmission nursing assessment and the initial wound assessment on 03/05/20 stated two stage one pressure ulcers. Review of the care plans revealed Resident #226 had a potential for impaired skin integrity related [MEDICAL CONDITION], alcohol dependence, hypertension, [MEDICAL CONDITION], malnutrition, and long term smoking. Resident #226 had a care plan in place for a skin tear to the left forearm and knee. There was no mention in the care plan of Resident #226 having actual skin breakdown with pressure ulcers noted. Interview on 03/12/20 at 3:22 P.M. with Registered Nurse (RN) #71 verified Resident #226's pressure ulcers were not care planned. Review of facilities Care Plan Policy, dated August 2014, revealed the resident's care plans are reviewed and revised by the interdisciplinary team quarterly, following completion of the MDS assessment, and following assessment for significant change. The care plan is individualized by identified resident problems, unique characteristics, strengths, and individual needs.

Based on medical record review, observations, staff interview and policy review, the facility failed to timely dispose controlled substances after resident's were discharged . This affected two (#230 and #229) of three controlled substance medication administration records reviewed. Facility census was 70. Findings include: Review of Resident #230 medical record, revealed an admission date of [DATE]. [DIAGNOSES REDACTED].#230 on respite care and discharged to home on [DATE]. Review of discharged Resident #230 medication administration record (dated February 2020) on [DATE], revealed last documented dose of controlled substance on [DATE] at 9:10 A.M., leaving four tablets of [MEDICATION NAME] in the blister pack. Review of Resident #229 medical record, revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Resident #229 passed away at facility on [DATE]. Review of discharge Resident #229 medication administration record (dated for February 2020) on [DATE], revealed last documented dose of controlled substance on [DATE] at 10:19 A.M., leaving approximately 26 milliliters (ml) of liquid [MEDICATION NAME] in the bottle. Observation of locked controlled substance drawer in East unit medication cart with Licensed Practical Nurse (LPN) #52 on [DATE] at 9:55 A.M., revealed Resident #230 blister pack of [MEDICATION NAME] and Resident #229 liquid [MEDICATION NAME] was in drawer. Interview with LPN #52 on [DATE] at 9:55 A.M., verified both Resident #230 and Resident #229 no longer resided at facility. LPN #52 stated the nursing staff notify the Director of Nursing (DON) when residents are discharged with controlled medications requiring disposal. LPN #52 did not know if the DON had been notified of the discharged residents. Interview with DON on [DATE] at 10:21 A.M., verified that the nursing staff notifies her of resident discharge and controlled medication disposal. DON stated she wasn't aware of two (#229 and #230) residents with controlled substances requiring disposal. Interview with DON on [DATE] at 10:21 A.M., verified that the nursing staff notifies her of controlled medication requiring disposal. DON stated she wasn't aware of any residents with controlled substances requiring disposal. Review of facility policy titled Disposal/Destruction of Expired or Discontinued Medications dated [DATE], revealed controlled medications are not to be returned to the pharmacy, but disposed by a Registered Nurse and witness who holds a professional license, the controlled medication is to be signed-off and amount destroyed is to be documented on the MAR.

Based on staff interview and record review, the facility failed to have written authorization to handle a resident's personal funds. This affected one (Resident #8) of five residents reviewed for resident accounts. The facility identified 37 residents with personal funds account. The facility census was 70. Findings include: Review of Resident #8's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment, dated 12/27/19, revealed the resident was severely cognitively impaired. Review of the undated 'Resident Fund Management' services form on 03/12/20 at 3:16 P.M. revealed there was not a signature for the facility to handle Resident #8's funds. Review of Resident #8's Resident Statement Landscape on 03/12/20 revealed her account was opened on 01/20/20 and had a current balance of $969.04. Interview with Business Office Worker #88 on 03/12/20 at 3:16 P.M. verified Resident #8's account was opened since 01/20/20 and the facility did not have a signed authorization to handle the funds.

Based on record review, resident and staff interview, the facility failed to follow physician orders [REDACTED]. This affected one (Resident #19) of the six residents reviewed for unnecessary medications. The facility census was 82. Findings include: Review of the medical record for the Resident #19, revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 03/18/19, revealed the resident was cognitively intact and did not reject care. Review of care plan, dated 03/15/19 for Resident #19, revealed to monitor weight as ordered. Review of the physician orders, dated 04/20/19, revealed the resident was to be weighed daily. Review of recorded weights for Resident #19, indicated last recorded weight was 05/21/19 using a mechanical lift. Review of the progress notes for Resident #19 revealed they were silent for the resident refusing daily weights or reasons for daily ordered weights not being completed. Interview with Resident #19 on 05/29/19 at 9:08 A.M. indicated he was being weighed daily but has not been weighed since returning from the hospital on [DATE]. Interview with Licensed Practical Nurse (LPN) #131 on 05/29/19 at 10:40 A.M. verified Resident #19 had physician orders [REDACTED].#131 verified Resident #19 was missing daily weights on 05/22/19, 05/23/19, 05/24/19, 05/25/19, 05/26/19, 05/27/19 and 05/28/19. Interview with Director of Nursing on 05/30/19 at 3:00 P.M. verified Resident #19 was missing daily weights on 05/22/19, 05/23/19, 05/24/19, 05/25/19, 05/26/19, 05/27/19 and 05/28/19.

Based on record review, staff interview and policy review the facility failed to complete comprehensive care plans. This affected one (Resident #81) of 18 resident care plans reviewed. The facility census was 82 Findings include: Record review revealed Resident #81 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 05/08/19, revealed Resident #81 had no cognitive deficits. Review of the physician order, dated 05/01/19, revealed to inspect [MEDICAL TREATMENT] for infection daily for localized pain, [DIAGNOSES REDACTED], warmth, [MEDICAL CONDITION] or abnormal drainage. Review of the care plans for Resident #81 revealed no care plan was completed for [MEDICAL TREATMENT] care. Interview on 05/30/19 at 2:00 P.M. with the Director of Nursing (DON) verified there was no care plan created for [MEDICAL TREATMENT]. Review of the facility policy on Care Plan, Comprehensive, dated 08/2014, revealed it was the policy of this facility to develop, in conjunction with the resident/and or representative, the comprehensive resident care plan. The care plan is directed toward achieving and maintaining optimal status of health, functional ability, and quality of life. It is completed no later than seven days after the completion of the Resident Assessment Instrument (RAI). It is reviewed and revised by the Interdisciplinary Team quarterly, following completion of the MDS assessment, and following assessment for significant change.

Based on record review and staff interviews, the facility failed to ensure that residents advanced directives were accurately documented in their electronic records. This affected two (Resident #34 and #60) of 24 residents reviewed for advanced directives. The facility census was 82. Findings include: 1. Review of Resident #34's records revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the resident's profile revealed the resident was Do Not Resuscitate (DNR). Review of signed advanced directives form revealed the resident wanted to be Do Not Resuscitate - Comfort Care Arrest (DNR-CCA). Interview on 05/28/19 at 1:09 P.M. with the Director of Nursing (DON) #123 verified the resident's advanced directives did not match in the electronic medical record to the original signed advanced directives form. 2. Review of medical record for Resident #60 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of signed advanced directives form revealed resident was listed as Do Not Resuscitate - Comfort Care (DNR-CC). Interview on 05/28/19 at 12:54 P.M. with Registered Nurse (RN) #300 verified Resident #60's electronic medical record and the original signed forms did not match.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on review of medical records, hospital records, Medication Administration Records (MAR), interviews with facility staff and review of facility policy, the facility failed to ensure residents were free from significant medication errors when one resident (#01), with a medical history of [REDACTED]. This resulted in Immediate Jeopardy and serious life-threatening harm for Resident #01 when the resident did not receive the physician ordered insulin, became hyperglycemic, and subsequently required admission to the Intensive Care Unit (ICU) with a hospital stay of four days. The resident was diagnosed with [REDACTED]. This affected one (#01) of three residents reviewed for insulin administration. The facility census was 85. On 04/26/19 at 5:02 P.M., the Administrator and Licensed Practical Nurse (LPN) #83 were notified Immediate Jeopardy began on 03/05/19 when Resident #01, with a medical history of [REDACTED]. Resident #01 did not receive physician ordered blood glucose monitoring or insulin from 03/05/19 through 03/10/19 when the resident became lethargic and had a blood glucose level of over 600 milligrams per deciliter (mg/dL). The resident was admitted to the hospital ICU on 03/10/19 and was hospitalized until 03/14/19 with [DIAGNOSES REDACTED]. Resident #01 required an insulin drip, electrolyte replacement, intravenous fluids, and every four-hour laboratory draws. The Immediate Jeopardy was removed on 03/12/19 when Resident #01 was sent to the hospital for medical evaluation and treatment, all other residents receiving insulin were reviewed, and in-service training regarding therapeutic medication interchanges, order processing, [MEDICAL CONDITION], and missing medications was completed with facility staff. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 03/23/18 when the facility implemented the following corrective actions: · On 03/10/19 at 10:27 A.M., Resident #01 was transferred to the hospital for evaluation and treatment. · On 03/10/19, the Director of Nursing (DON) completed a review of Resident #01's medical record. During the review, the medication error was discovered, and a Medication Error Form was completed by Registered Nurse (RN) #11. · On 03/10/19, LPN #83 completed an audit of all insulin-dependent residents to ensure their diabetic medication orders were accurate and being properly administered. No other diabetic medication orders were found to be noncompliant. · On 03/10/19 at 8:00 A.M., LPN #83 began conducting education and in-servicing of all licensed nursing staff related to inputting and reviewing admission orders [REDACTED]. During general orientation, all new hires since 03/10/19 have received the same education. The education was completed on 03/12/19 at 6:00 P.M. · On 03/11/19, the DON audited all residents receiving insulin for accuracy of orders with no concerns noted. The facility completed monitoring of insulin order accuracy for residents on 03/12/19, 03/14/19, 03/15/19, 03/17/19, 03/18/19, 03/20/19, and 03/23/19. · On 04/26/19 at 5:00 P.M., LPN #83, initiated re-educating the licensed nursing staff related to therapeutic interchange instructions, insulin administration, signs and symptoms of hyper/[DIAGNOSES REDACTED], and reviewing medication/physician orders [REDACTED]. Moving forward, therapeutic interchanges will be approved by the DON or Assistant Director of Nursing (ADON) and orders will not be changed or deleted without approval. All education was completed by (MONTH) 29, 2019 by 8:00 A.M. · On 04/26/19 at 6:26 P.M., Resident #01 was reassessed by RN #11 and the resident was found to be at baseline with no adverse affects noted. · On 04/27/19 from 8:00 A.M. to 6:00 P.M., all medication carts were audited by Regional Registered Nurse (RRN) #44, and LPN #83. Medications in the carts were cross-referenced to physician orders [REDACTED]. · As part of the facility's ongoing Quality Assurance/Performance Improvement program, the Charge Nurse/ADON/Designee will audit 100 percent of diabetic residents MARs three to five times weekly to ensure all insulin orders are being administered as ordered. This audit will continue for the next six months, if no additional concerns are identified the audit will be moved to monthly. · Interview with on 04/29/19 starting at 2:25 P.M. revealed LPN #22, LPN #30 and RN #31 indicated they received training on therapeutic medication interchanges, order processing, [MEDICAL CONDITION], and missing medications. Findings include: Review of Resident #01's medical record revealed an admission date of [DATE] to the facility from the hospital. The resident's primary admitting [DIAGNOSES REDACTED]. Review of the hospital discharge summary dated 03/04/19 revealed she was admitted to the hospital on [DATE] and was discharged [DATE] to the nursing facility. The residents primary discharge [DIAGNOSES REDACTED]. The resident was found on the floor at home by her home health nurse. The resident was unable to make medical decisions regarding her care due to her dementia. Resident #01 presented to the hospital from home with a blood sugar of 1056 mg/dL and diabetic ketoacidosis. Review of the hospital discharge summary continuity of care dated 03/04/19 revealed Resident #01 was to receive an injection of 30 units of [MEDICATION NAME] (insulin [MEDICATION NAME]) insulin pen subcutaneously daily. The resident was also to receive an injection of seven units of [MEDICATION NAME] (generic brand - insulin [MEDICATION NAME]) subcutaneously three times a day before meals. The resident was to receive blood glucose fingerstick monitoring before each meal and at bedtime and receive sliding scale insulin according to a sliding scale. Review of Resident #01's Physician order [REDACTED]. The order was discontinued on 03/04/19 at 11:10 P.M and was replaced for a pharmacy therapeutic interchange. The new medication was Basaglar Kwikpen inject 30 units every day subcutaneously therapeutic interchange-[MEDICATION NAME]. Review of the Physician order [REDACTED].#01 also revealed orders for [MEDICATION NAME] 100 units/1 milliliter (ml) insulin pen, inject seven units subcutaneously three times a day for diabetes mellitus. The order was discontinued on 03/05/19 and was replaced for a pharmacy therapeutic interchange. The new medication was Humalog 100 units/1 milliliter insulin vial, inject seven units, three times a day for diabetes mellitus therapeutic interchange [MEDICATION NAME]. Review of the MAR from 03/04/19 to 03/10/19 revealed Resident #01 received 30 units of [MEDICATION NAME] on 03/04/19 in the evening. The resident received [MEDICATION NAME] 7 units on 03/05/19 at 8:00 A.M. and 11:30 A.M. The resident did not receive any more insulin injections until she was discharged to the hospital on [DATE]. Review of the MAR indicated [REDACTED].M. revealed an order which indicated pending confirmation Basaglar Kwikpen U-100, inject 30 units subcutaneously daily. Resident #01 also had a pending confirmation Humalog 100 unit/ 1 ml insulin vial, inject seven units subcutaneously three times a day dated 03/05/19 at 1:09 P.M. Neither medication was confirmed or administered. Review of Resident #01's medical record revealed no blood glucose fingerstick monitoring was completed before meals and at bedtime from 03/04/19 to 03/10/19. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 had short and long-term memory problems and was moderately cognitively impaired for making decisions regarding tasks of daily life. The resident required extensive assistance of one person for bed mobility, transfers, walking in room and corridor, personal hygiene, and toilet use. Review of a Situation, Background, Assessment, Recommendation (SBAR) assessment dated [DATE] at 10:27 A.M. revealed Resident #01 was hyperglycemic and lethargic with decreased consciousness, unsteady gait, and disorganized thinking. The resident required more assistance with activities of daily living and had slurred speech. Review of LPN #22's progress notes dated 03/10/19 at 10:28 A.M. revealed Resident #01 was transferred to an acute care hospital due to [MEDICAL CONDITION] (increased blood glucose levels). Review of Resident #01's hospital History and Physical dated 03/10/19 revealed Resident #01 was seen and admitted to the hospital for [MEDICAL CONDITION] and was admitted with a blood sugar greater than 600 mg/dL. The hospital records indicated the review of the electronic health record revealed she had not been receiving her insulin at the nursing facility. The resident was admitted to the ICU with the primary [DIAGNOSES REDACTED]. The resident was placed on an insulin drip, electrolyte replacement, intravenous fluids, and every four-hour laboratory draws. The resident also was diagnosed with [REDACTED]. Review of Resident #01's hospital discharge summary dated 03/14/19 at 2:37 P.M. revealed the resident was discharged back to the nursing facility. Interview with LPN #22 on 04/26/19 at 9:35 A.M. revealed she admitted Resident #01 on 03/04/19 to the facility and wrote the orders for her insulin to be administered per the hospital discharge continuity of care form. LPN #22 stated when she worked with Resident #01 on 03/10/19, she noticed the insulin orders were not being administered. LPN #22 reviewed the electronic record and noted that her original order for [MEDICATION NAME]pen and [MEDICATION NAME] had been changed out for a therapeutic interchange to different insulins and they were still pending confirmation in the computer. LPN #22 took Resident #01's blood glucose level and the meter read high which usually indicates a blood glucose level over 600 mg/dL. Resident #01 was sent to the hospital. Interview with ADON #83 on 04/26/19 at 10:30 A.M. verified Resident #01 was admitted to the facility on [DATE] and LPN #22 transcribed the discharge instructions from the hospital continuity of care paperwork. ADON #83 indicated the pharmacy did a therapeutic interchange of the two injectable insulins but it was not verified and transcribed over to the electronic MAR. ADON #83 verified Resident #01 did not receive her insulin from 03/05/19 at 11:30 A.M. until 3/10/19 when she was sent out to the hospital. LPN #83 verified the resident was supposed to get 30 units once a day and seven units three times a day for a total of 51 units a day which she did not receive for over four days. Interview with the Administrator on 04/26/19 at 4:35 P.M. verified Resident #01's primary admitting [DIAGNOSES REDACTED]. Interview with Regional Registered Nurse (RRN) #44 on 04/29/19 at 3:40 P.M. verified the hospital discharge paperwork continuity of care form indicated Resident #01 was supposed to receive blood glucose monitoring every day before meals and at bedtime and verified it was not transcribed to the physician's orders [REDACTED]. Further interview with RRN #44 on 04/29/19 at 3:44 P.M. revealed the facility does not have a policy for transcribing hospital discharge continuity of care papers for new admissions, however, it was a standard of practice and the expectation was to transcribe all orders and verify with the physician any questionable orders from the hospital. Review of a facility policy titled Physician/Prescriber Authorization and Communication of Orders to Pharmacy dated 10/01/18 revealed the facility should review any pharmacy communication letters attached to medications including pharmacy notification of medication therapeutic interchange and make any necessary changes in the resident's physician orders [REDACTED]. This deficiency substantiates complaint OH 767.

Based on record review, staff interview, investigation report review, emergency squad report review, emergency records review and pharmaceutical reference review, the facility failed to ensure nurses administered medications without significant errors. Two registered nurses (RNs) failed to properly prepare medications and properly identify a resident resulting in administration of eight medications to the wrong resident, including antidiabetic medications, duplicate diuretic and antihypertensive medications and a medication to which the resident had an allergy. This resulted in Resident #70 experiencing [DIAGNOSES REDACTED], [MEDICAL CONDITION] and emergency medical transportation and care. This affected one (Resident #70) of three sampled residents. Findings included: The clinical record face sheet dated 08/08/10 stated Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital transfer sheet stated Resident #70 was admitted to the facility after a hospital stay from 08/15/10 through 08/18/10 after treatment for [REDACTED]. The MDS further documented Resident #70 required extensive assistance of staff for activities of daily living, received occupational and physical therapy, had allergies [REDACTED]. The admission medication list documented the resident's allergy to aspirin. Review of Resident #70 's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. medications as ordered by the physician: [MEDICATION NAME] 10 milligrams (mg) ([MEDICAL CONDITION] and antihypertensive medication); [MEDICATION NAME] 3.125 mg (antihypertensive medication); [MEDICATION NAME] 80 mg (diuretic and antihypertensive medication); [MEDICATION NAME] 300 mg (anticonvulsant used for nerve pain); Klor Con 20 meq (potassium supplement); [MEDICATION NAME] 112 micrograms ([MEDICAL CONDITION] replacement hormone); [MEDICATION NAME] 10 mg ([DIAGNOSES REDACTED]drug); and [MEDICATION NAME] 20 mg (antiulcerative and reflux drug). Nursing notes dated 09/04/10 at 10:50 A.M. stated the resident "mistakenly took medications of another resident". The facility investigated the incident. Review of the investigation revealed a written timeline of events. The timeline stated on 09/04/10 at 7:30 A.M., Resident #70 received her medications from RN #18. At 8:30 A.M., RN #66 arrived to assist RN #18 with the medication pass. The only medications left to administer were for Resident #72. RN #18 prepared the medications for Resident #72 and handed them to RN #66 to administer to Resident #72. RN #18 pointed out whom she thought was Resident #72 (seated in a wheelchair in the hallway) and told RN #66 to give the medications to that resident. The investigation further stated RN #66 administered the medications to the resident RN #18 pointed out for her. After administering the medications to the resident in the hallway of the facility, RN #66 entered the room of Resident #72 to set up a breathing treatment. Resident #72 was in her room and was not the resident RN #66 had just given medications to in the hallway. The investigation documented RN #66 realized at that moment she had given the medications to Resident #70 and not to Resident #72. The investigation revealed Resident #70 received the following medications, which were ordered by the physician for Resident #72: [MEDICATION NAME] 10 mg and [MEDICATION NAME] 500 mg (oral antidiabetic medications); [MEDICATION NAME] 75 mg (platelet medication); [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg (antihypertensive); aspirin 81 mg (anti-[MEDICAL CONDITION] and anticoagulant); [MEDICATION NAME] 3.125 mg (antihypertensive); [MEDICATION NAME] 40 mg (diuretic and antihypertensive); and KDur 10 meq (potassium supplement). The investigation documented the physician was informed and gave an order to monitor the blood glucose of Resident #70 every hour, as she was not diabetic (and received two antidiabetic medications). Other monitoring parameters were not specified and the record did not include documentation of ongoing monitoring, including BP, pulse, fluid intake, urine output. According to The Lippincott Manual of Nursing Practice, 7th edition page 53, the normal range for systolic BP is 95 - 140 and the normal range for diastolic BP is 60 - 90. Review of nursing notes revealed finger stick blood sugar (FSBS) tests were completed as ordered by the physician. The last FSBS was documented at 9:30 P.M. on 09/04/10 and was 276 (normal = 60 - 100). On 09/05/10 at 5:30 A.M., nursing notes documented the resident's vital signs: temperature 98.8; pulse 81, blood pressure (BP) 90/50, respiration 18 and oxygen saturation 81% (normal = 95% - 100%). The nurse applied oxygen and the oxygen saturation changed to 90%. The FSBS was not assessed. Nursing notes dated 09/05/10 at 6:50 A.M. stated Resident #70 was found unresponsive, flaccid with a positive gag reflex. Her FSBS was "too low to register on the glucometer." The nurse administered instant glucose, the FSBS assessed and remained low. The nurse administered five packs of sugar and at 7:15 A.M. and Resident #70 remained unresponsive. Nursing notes dated 09/05/10 at 7:20 A.M. revealed the nurse administered a subcutaneous [MEDICATION NAME] injection, the FSBS was assessed and was 28. The nurse administered an additional instant glucose and at 7:25 A.M., the FSBS was 61. At 7:35 A.M., the resident's FSBS was 75 and her eyes opened with stimulation. At 7:40 A.M., her oxygen saturation was 70%, BP was 90/46. At 8:05 A.M., Resident #70 had wheezes (lungs sounds) bilaterally and BP decreased to 82/43. At 8:10 A.M., the resident was transferred to the hospital by ambulance. According to the Life Squad report dated 09/05/10, the ambulance was dispatched at 7:52 A.M. and was on scene at 8:05 A.M. The chief complaint was "unresponsive"; BP was 71/41 and FSBS was 132. Hospital emergency room (ER) records revealed Resident #70 was admitted to the ER at 8:20 A.M. Intravenous fluids were administered. Physician notes dated 09/05/10 at 8:55 A.M. documented "Medical Decision Making": the resident was "hypotensive from [MEDICATION NAME] ([MEDICATION NAME]) and [MEDICATION NAME]" and "hypoglycemic". [DIAGNOSES REDACTED]. The facility Administrator was interviewed on 10/01/10 at 10:30 A.M. She affirmed Resident #70 was administered Resident #72's medications when RN #18 prepared the medications and told RN #66 to administer them. The Administrator further stated RN #18 mistakenly identified Resident #70 as Resident #72 and RN #66 gave the medications to the wrong resident. The Administrator stated RN #66 reported she knew she should not have administered medications she did not prepare herself. According to Nursing 2011 Drug Handbook: [MEDICATION NAME] is an antidiabetic medication to lower glucose level in patients with type II diabetes. Action is unknown: probably stimulates insulin release from the pancreas, reduces glucose output by the liver and increases peripheral sensitivity to insulin. Dosing guidance for extended release states: for patients older than 65, first dose is 5 mg daily. (Resident #70 received 10 mg.) The extended release onset of action is 2 - 3 hr, peak in 6 - 12 hours and duration is 24 hours. Adverse reactions and overdose signs and symptoms include: [DIAGNOSES REDACTED]. [MEDICATION NAME] is an antidiabetic medication to lower glucose level in patients with type II diabetes. Initial dose is 500 mg twice daily. For elderly patients, dosage should be conservative because of potential decrease in renal function. Conventional dose onset is unknown, peak is 2 - 4 hr and duration of action is unknown (half life is about six hours). Drug interactions include use with beta blockers ([MEDICATION NAME]): [DIAGNOSES REDACTED] may be difficult to recognize. Monitor patient and blood glucose. [MEDICATION NAME] has a "Black Box Warning: because of risk of lactic acidosis, drug is contraindicated in patients older than 80, unless creatinine clearance indicates normal renal function. Also, use caution when giving drug to elderly, debilitated patients because if increased risk of [DIAGNOSES REDACTED]. [MEDICATION NAME] (beta blocker) is an antihypertensive. Adverse reactions include [MEDICAL CONDITION], syncopy, heart block. Drug - drug interactions include antidiabetics ([MEDICATION NAME], [MEDICATION NAME]): may enhance hypoglycemic properties; use cautiously. [MEDICATION NAME] is a diuretic used to manage [MEDICAL CONDITION] associated with [MEDICAL CONDITION] or used alone or in combination with antihypertensives to treat hypertension. Warnings include, coadministration of antihypertensives (including [MEDICATION NAME]) may increase the risk of [MEDICAL CONDITION] (low blood pressure). Drug interactions include use with ACE inhibitors ([MEDICATION NAME]) and have hypotensive effects potentiated by hypovolemia. Adverse reactions include orthostatic [MEDICAL CONDITION]. Nursing considerations include: Monitor weight, blood pressure and pulse routinely with long term use. Monitor fluid intake and output. Monitor elderly patients who are especially susceptible to excessive diuresis. A "black box warning" stated: Drug is a potent diuretic and can cause severe diuresis with water and electrolyte depletion. Monitor patient closely. [MEDICATION NAME] ([MEDICATION NAME]) is an angiotensin converting enzyme (ACE) inhibitor used in the treatment of [REDACTED]. Warnings include, use with caution in hypovolemia. Drug interaction revealed, hypovolemia due to diuretics may precipitate acute hypotensive events or acute [MEDICAL CONDITION]. Special geriatric considerations included, many older adults may be volume depleted due to diuretic use and [MEDICATION NAME] thirst reflex resulting in inadequate fluid intake. Monitor blood pressure frequently. This citation substantiated Complaint Control Number OH 745.