Every finding on record at Walnut Hills Nursing Home

Based on observation, interview and review of the laundry check-list, the facility failed to ensure the dryer lint vents were free from build up. This had the potential to affect all residents residing in the facility. The facility census was 38.Findings include:An observation on 06/25/26 at 8:12 A.M. revealed an empty dryer with the lint trap screen covered with large amount of lint build-up. Further observation revealed lint build-up on the bottom of the dyer below the lint trap screen.An interview on 06/25/26 at 8:14 A.M. with Laundry Staff (LS) #218 verified the lint build up on the lint screen and in the bottom of the dryer. LS #218 stated the dryer lint trap screens were cleaned at the end of each shift. An interview on 06/25/26 at 10:15 A.M. with the Administrator revealed the facility had no policy to review concerning dryer lint trap cleaning.Review of the facility's laundry checklist revealed laundry staff were responsible at the end of each shift to clean the lint trap screens for the dryers.

Based on medical record review and staff interview, the facility failed to ensure the Advanced Directive code status was consistent throughout the medical record. This affected two (#7 and #19) of two residents reviewed for code status, with the potential to affect all residents except for six (#6, #15, #16, #28 and #43) who were identified as having a full code status. The facility census was 38. Findings include:1. Review of Resident #19's medical record revealed an admission date of [DATE], with a diagnosis of chronic systolic congestive heart failure.Review of the care plan initiated [DATE] revealed Resident #19 had a Do Not Resuscitate Comfort Care (DNRCC - aggressive or invasive medical interventions are stopped right away) code status. Interventions included to ensure direct care staff knew the code status.Review of Resident #19's paper medical record revealed a red paper at the front of the chart indicating the resident had a Do Not Resuscitate (DNR - do not perform cardiopulmonary resuscitation [CPR] but continue other routine treatments) code status. Further review of the Advanced Directives section revealed a form titled, DNR Order Form dated [DATE]. Resident #19's name was printed at the top of the form, and it was signed by the resident's representative. The form had two options to choose from, Do Not Resuscitate Comfort Care Arrest (DNRCC-A) (full, aggressive treatments continue until the heart or breathing completely stops) and the second option was DNRCC. The DRNCC-A box was marked with an X and signed by Certified Nurse Practitioner (CNP) #600.Review of the physician order dated [DATE] revealed Resident #19 had an order for a DNRCC code status. Interview on [DATE] at 3:01 P.M. with Licensed Practical Nurse (LPN) #601, and concurrent review of Resident #19's paper medical record, confirmed the red page, upon opening the record, revealed the resident had a DNR only code status. Further interview and review of the paper medical record confirmed Resident #19 had a DNRCC-A code status located under the Advanced Directives section and the physician order in the electronic medical record (EMR) showed the resident had a DNRCC code status. When asked which order should be followed, LPN #601 hesitated and revealed she was an agency nurse and would likely follow the physician order in the EMR. Interview on [DATE] at 3:04 P.M. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #264 confirmed Resident #19's code status was not clear, the Advanced Directives did not match the order documented, and the red form in front of the chart was not clear or complete to determine DNRCC or DNRCCA. The DON confirmed there was a difference in the care provided for residents with a DNRCC and a DNRCC-A code status that could make a difference between life and death. ADON #264 stated all residents, who were not a full code status, had the red paper in the paper medical record that indicated DNR code status but confirmed the document did not specify if the resident had a DNRCC or DNRCC-A code status. 2. Review of Resident #7's medical record revealed an admission date of [DATE]. Diagnoses included dysarthria and anarthria.Review of Resident #7's paper medical record revealed a red paper at the front of the record indicating the resident had a DNR code status. Further review of the Advanced Directives section revealed a form titled, DNR Order Form dated [DATE]. Resident #7's name was printed at the top of the form and was signed by the resident. Physician #603 signed the document on [DATE]. Further review revealed Resident #7's code status was DNRCC-A.Interview on [DATE] at 2:52 P.M. with LPN #256 revealed if she needed to find a resident's code status, she would use either the paper medical record or the EMR, depending on which was closer to get to. Interview on [DATE] at 3:06 P.M. with the DON confirmed Resident #7's code status was not clear, with the red form in the front of the paper medical record showing DNR but not specifying if the resident was a DNRCC or a DNRCC-A code status.

Based on observation, interview and record review, the facility failed to ensure medications were not left at a resident's bedside and further failed to ensure medications were not expired. This affected one (#21) of five residents reviewed for medication administration. Additionally, the facility failed to ensure medications were not left unattended and unsecured on a medication cart. This had the potential to affect 10 (#5, #12, #14, #19, #21, #22, #18, #31, #33, and #36) residents identified by the facility as being independently mobile. The facility census was 38.Findings include: 1. Record review for Resident #21 revealed an admission date of [DATE]. Diagnoses included Parkinson's disease, nonexudative age-related macular degeneration left eye, intermediate dry stage, nonexudative age-related macular degeneration right eye advanced atrophic without sub foveal involvement and dry eye syndrome of bilateral lacrimal glands.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively intact and had impaired vision.Review of the care plan initiated [DATE] revealed Resident #21 had impaired visual function related to diagnosis of right eye end stage macular degeneration and moderate macular degeneration in the left eye, hypertensive retinopathy, and a history of dry eye syndrome. Further review of Resident #21's care plan revealed no documentation of self-administration of eye drops. Review of the current physician orders revealed Resident #21 had an order for Systane Ultra, instill one drop in both eyes two times a day related to dry eye syndrome of bilateral lacrimal glands. Further review revealed no physician order for the self-administration of eye drops.Observation on [DATE] at 8:40 A.M. during medication administration with Medication Aid (MA) #519 revealed Resident #21 had two vials of Visine eye drops on the bedside table next to the resident. Further observation revealed the expiration date on one partially used vial was [DATE] and the second vial expired [DATE]. MA #519 verified both vials of Visine eye drops were expired. Concurrent interview with Resident #21 confirmed she still used both vials occasionally as needed. MA #519 exited the room without removing the vials.Interview on [DATE] at 8:50 A.M. with Licensed Practical Nurse (LPN) #325 verified Resident #21 was unable to self-administer her own eye drops. LPN #325 stated that a long time ago, Resident #21 was able to administer her own eye drops but since her decline, she could and should not have eye drops left in her room. 2. Observation on [DATE] at 9:17 A.M. of the long-term care medication cart revealed an unopened lidocaine four percent (%) pain relief patch lying on top of the medication cart, with no nursing staff visible in the area. Continued observation revealed at 9:20 A.M., visitors were conversing near the medication cart and additional non-nursing staff and residents passed near the medication cart. Interview and concurrent observation on [DATE] at 9:23 A.M. with the Director of Nursing (DON) verified the lidocaine patch was left unsecured on the medication cart. The DON confirmed medications should not be left unattended on the medication carts.

Based on medical record review, review of a facility Self-Reported Incident (SRI), resident and staff interviews and review of facility policy, the facility failed to ensure allegations of abuse were thoroughly investigated. This affected one (#24) of three residents reviewed for abuse. The facility census was 38.Findings include:Review of Resident #24's medical record revealed an admission date of 06/23/22. Diagnoses included multiple sclerosis and unspecified psychosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was mildly cognitively impaired. Resident #24 had impairment on both sides of the upper and lower extremities and required assistance with activities of daily living (ADLs). Resident #24's hearing was adequate, made self-understood, was able to understand others. Resident #24 had no hallucinations or delusions.Review of the facility initiated SRI, dated 06/05/26, revealed the charge nurse on the North Unit, where Resident #24 resided, received a call from his brother at approximately 9:20 P.M. on 06/05/26. He stated his mother, who had been visiting the resident earlier that evening, returned home and called him to tell him that the resident told her that he had been raped the day before. The Administrator was notified. The charge nurse performed a full assessment of the resident and there was no sign of trauma or injury. The Administrator called the resident's mother upon arriving at the facility to confirm what she had told her other son. The resident was interviewed by the Director of Nursing (DON) and the Administrator, and he stated that a woman, who he had never seen before, came into his room the previous day, had her way with me, and left the room without saying a word. When questioned, he stated that he was in bed for the night, not in his recliner, and that it was before it got dark. The resident was unable to give a description. Staff were interviewed and stated they did not see anyone in the facility that they did not know or recognize. The allegation was unsubstantiated.Review of the staff schedule for 06/04/26 revealed 12 staff, including Certified Nursing Assistant (CNA) #234, CNA #317, CNA #420, Licensed Practical Nurse (LPN) #515, Culinary Aid (CA) #222, CA #604, [NAME] #335, CNA #226, CNA #240, CNA #323, CNA #361 and LPN #212 were working during the time of the alleged sexual abuse. Interview on 06/24/26 at 2:46 P.M. with the Administrator and the DON, and concurrent review of the facility investigation, revealed four staff members (CNA #234, CNA #317, CNA #420, and LPN #515) were interviewed during the facility investigation. The DON revealed she completed the staff interviews, and she determined the time frame must have been between dinner and bedtime, so around 5:00 P.M. to 7:30 P.M., because Resident #24's mother visited that day until right before dinner and the resident said it was still light outside when the rape occurred. The Administrator confirmed eight (CA #222, CA #604, [NAME] #335, CNA #226, CNA #240, CNA #323, CNA #361 and LPN #212) were working the evening of 06/04/26 and were not interviewed as part of the facility investigation. The Administrator verified that all staff who were present in the facility at the time of the alleged sexual abuse were not interviewed but should have been. Interview on 06/24/2026 at 4:32 P.M. with Resident #24 revealed the resident alleged he was raped by a female on 06/04/26. The resident stated it was daylight outside at the time of the alleged incident. Resident #24 stated he did not know if the female was a staff or not, adding he never met dietary staff or most of the housekeeping staff and he did not know all of the nurses or CNAs. Resident #24 was unable to provide a description of the female. Review of the facility policy titled, Abuse Investigation Protocol, revised April 2024, revealed the facility investigation included identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation.

Based on medical record review, observation and interview, the facility failed to ensure physician ordered treatments were completed by licensed nursing staff. This affected one (#28) of three residents reviewed for quality of care. The facility census was 38.Findings include:Review of Resident #28's medical record revealed an admission date of 11/22/24, with diagnoses including cellulitis of the left lower limb.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact, had impairment on both sides of the upper and lower extremities and required assistance with activities of daily living (ADLs). Resident #28 had no pressure ulcers, wounds or skin concerns. Review of the care plan revised 06/17/26 revealed Resident #28 had the potential for impairment to skin integrity related to a history of sepsis, bilateral lower extremity cellulitis and lymphedema. Interventions included following the facility protocol for treatment of injury and monitor the wound for signs and symptoms of infection (redness, drainage, swelling, warmth) and report changes promptly. Review of a physician order dated 10/14/25 revealed to apply Ace wraps to Resident #28's bilateral lower legs in the morning one time a day for edema. Further review of the Treatment Administration Record (TAR) for June 2026 revealed licensed nursing staff signed off on the TAR daily indicating the treatment was completed. Review of the History and Physical report dated 06/24/26 and authored by Certified Nurse Practitioner (CNP) #605 revealed Resident #28 presented after hospitalization from 06/07/26 to 06/15/26 for diagnoses which included septic shock due to Streptococcus agalactiae bacteremia with left lower extremity cellulitis. The Assessment and Plan included to continue oral penicillin as per infectious disease recommendations and monitor for any signs of recurrent infection.Observation on 06/25/26 at 10:20 A.M. revealed Resident #28 was sitting up in her chair in her room. Concurrent interview with Certified Nursing Assistant (CNA) #220 revealed she just completed morning care for Resident #28 and was going to apply the resident's Ace wraps to her bilateral lower legs. CNA #220 revealed she normally applied Resident #28's Ace wraps on the days she worked and further revealed she was never trained on the proper application of the Ace wraps. Continued observation revealed Resident #28's bilateral lower extremities were swollen, and both were discolored. Interview on 06/25/26 at 11:04 A.M. with the Director of Nursing (DON) verified the licensed nurse should apply Ace wraps because it was out of the scope of practice for CNAs to do. The DON further stated the licensed nurse would need to apply the Ace wraps to Resident #28's lower extremities in order to monitor the resident's legs due to recent sepsis/cellulitis.

Based on medical record review, staff interviews and review of facility policy, the facility failed to implement non-pharmacological interventions prior to the administration of pain medications. This affected one (#11) of five residents reviewed for unnecessary medication. The facility census was 38. Findings include:Review of Resident #11's medical record revealed an admission date of 04/24/23 with diagnoses including, but not limited to, chronic pain, anxiety, depression, and chronic respiratory failure.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 has a pain program and received scheduled and as needed pain medication without non-pharmacological interventions used.Review of Resident #11's physician orders revealed an order dated 04/01/25 for oxycodone 10 milligram (mg), give one tablet by mouth every two hours as needed (PRN) for pain.Review of the Medication Administration Record (MAR) for June 2026 revealed on 06/03/26 at 2:06 A.M., Resident #11 received PRN oxycodone 10 mg for pain, with no non-pharmacological interventions implemented prior to medication administration. Further review revealed on 06/15/26 at 10:44 A.M., Resident #11 received PRN oxycodone 10 mg for pain, with no non-pharmacological interventions implemented prior to medication administration.Review of Resident #11's progress notes from 06/01/26 to 06/24/26 revealed no evidence that non-pharmacological interventions were attempted prior to PRN pain medication being administered.Interview on 06/24/26 at 7:40 A.M. with Licensed Practical Nurse (LPN) #325 revealed non-pharmacological interventions were implemented and documented in the MAR progress notes prior to administration of PRN pain medications.Interview on 06/24/26 at 9:55 A.M. with the Director of Nursing (DON) verified Resident #11 did not have any pain non-pharmacological interventions implemented prior to the administration of PRN pain medication. The DON stated non-pharmacological interventions were implemented as of 06/24/26.Review of the facility policy titled, Pain - Clinical Protocol, dated 02/11/26, revealed the physician would order appropriate non-pharmacologic and medication interventions to address the individual's pain.

Based on record review, observation, interview and review of facility policy, the facility failed to ensure enhanced barrier precautions (EBP) were followed during wound care. This affected one (#23) of three residents reviewed for transmission-based precautions (TBP). The facility census was 38.Findings include:Review of Resident #23's medical record revealed a readmission date 04/30/26 with diagnoses including, but not limited to, heart disease, epilepsy, vascular dementia, and anxiety.Review of the significant change [NAME] Data Set (MDS) assessment dated [DATE] revealed Resident #23 had severe impaired cognition and was dependent on staff for all Activities of Daily Living (ADLs).Review of Resident #23's physician orders revealed orders dated 06/16/26 to cleanse the right outer heal with saline, pat dry, apply Alginate, cover with foam dressing, and change three times a week and as needed (PRN) in the morning every Tuesday, Thursday, Saturday for wound care and as needed for soiling or lifting and apply Triad paste to the right hallux tip (big toe) daily in the morning for wound care and as needed for skin irritation. Further review revealed an order dated 06/18/26 for EBP related to wounds.Review of the care plan, revised 06/18/26, revealed Resident #23 was on EBP related to wounds.Observation on 06/23/26 from 10:12 A.M. to 10:30 A.M. revealed Registered Nurse (RN) #319 and Certified Nurse Practitioner (CNP) #550 entered Resident #23's room to complete wound care for the right outer heel wound and the right hallux tip wound. On the door of Resident #23's was notification signage for EBP. Continued observation revealed RN #319 and CNP #550 washed their hands and placed gloves on but did not don a gown. RN #319 removed the soiled dressing from Resident #23's right outer heel and cleansed the area with saline. CNP #550 measured the area and RN #319 placed the new dressing. RN #319 removed the gloves and washed her hands prior to exiting the resident's room.Interview on 06/23/26 at 10:40 A.M. with RN #319 verified neither she nor CNP #550 donned a gown prior to completing Resident #23's wound care. RN #319 stated her understanding of EBP was for chronic wounds. RN #319 stated Resident #23's wounds were not chronic, therefore EBP were not followed during wound care.Review of the facility's policy titled, Enhanced Barrier Precautions, dated 06/12/25 revealed high - contact resident care activities included wound care, defined as any skin opening requiring a dressing.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record reviews, reviews of a facility investigation, review of self-reported incidents (SRIs), and review of a facility policy, the facility failed to ensure residents were free from misappropriation. This affected two (#4 and #47) of two residents reviewed for misappropriation. The facility census was 47. Findings include: Review of the medical record for Resident #4 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure, and depression. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 was unable to be interviewed and was dependent on staff for activities of daily living (ADLs). Review of the physician's orders for December 2024 revealed Oxycodone (narcotic pain medication) 20 milligrams (mg) given every six hours routinely and a as needed (PRN) order for five mg of Oxycodone every two hours. Review of the medical record for Resident #47 revealed an admitted [DATE] with diagnoses including cerebral palsy, major depressive disorder, and generalized anxiety disorder. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #47 had intact cognition and was dependent on staff for ADLs. Review of the physician's orders for December 2024 revealed Oxycodone five mg twice daily and a as needed (PRN) order for five mg of Oxycodone every four hours. Review of the SRI dated 01/09/25 revealed Licensed Practical Nurse (LPN) #108 signed out as needed (PRN) Oxycodone immediate release (IR) five milligrams (mg) for Resident #4 on 12/31/24 at 7:20 P.M. and 9:50 P.M. and on 01/01/24 at 4:00 A.M. on one narcotic count card and on another narcotic card for Resident #4 revealed Oxycodone IR 20 mg signed out at 7:20 P.M. on 12/31/24 as well as 12:00 A.M. and 5:00 A.M. on 01/01/25 in the narcotic count book. Resident #4's medication administration records (MARs) for December 2024 and January 2025 did not reveal that the PRN five mg. Oxycodone IR was administered to Resident #4 by LPN #108. Further review of the MARs for 12/31/24 and 01/01/25 revealed that they were not signed off and that Oxycodone IR 20 mg was not due at the times when taken from cart. Resident #4 was unable to verify she received it. Resident #4's habit was to sleep through the night and normally does not get the Oxycodone IR five mg at night. Additionally, the SRI revealed LPN #108 signed out PRN Oxycodone IR five mg for Resident #47 out at 7:00 P.M. and 11:10 P.M. on 12/31/24 and 3:14 A.M. on 01/01/25 on a card in the narcotic count book. Resident #47's MARs for December 2024 and January 2025 did not reveal that the PRN five mg. Oxycodone IR was administered to Resident #47 by LPN #108. Resident #47 denied that she was woken up to receive PRN Oxycodone through the night. Resident #47 verified that she received her routine medication at 9:00 A.M. and 5:00 P.M. by LPN #109. Resident #47's habit was to sleep through the night and normally does not get Oxycodone five mg at night. The facility's investigation revealed after LPN #108 left for the day, LPN #102 looked closer at the narcotic sheets for Resident #4 and found discrepancies which prompted the investigation. The facility substantiated the SRI and reported LPN #108 to the Ohio Board of Nursing (OBN), Ohio Board of Pharmacy (OBP), and the Local Police Department (LPD). An interview on 03/12/25 at 1:00 P.M. with the Administrator stated she was in training when the incident occurred and verified LPN #108 misappropriated Residents #47 and #4's narcotic medications. Review of the facility policy titled Controlled Substance Administration and Accountability Policy, dated 04/08/23 revealed the facility will have safeguards in place to prevent loss, diversion or accidental exposure. The deficient practice was corrected on 01/23/25 when the facility implemented the following corrective actions: On 01/01/25 at 10:00 A.M. all residents on North Hall were assessed for pain and accuracy of narcotics and no further issues were noted by the Former Director of Nursing (FDON) #110. On 01/01/25 at 10:30 A.M. the Medical Director #112 was notified and it was discussed her next steps in notification. On 01/01/25 at 11:00 A.M., FDON #108 reported the incident to the agency that LPN #108 was employed and put on the do not return list. On 01/02/25 at 2:00 P.M., FDON #108 notified the OBN asking for additional guidance to ensure all appropriate entities were notified. On 01/02/25 at 3:10 P.M., FDON #108 reported the incident to the local police department. Report #25HC00022. On 01/23/25, all nurses and medication technicians were in-service on controlled substance policy, and medication administration policy. This was an incidental finding during the course of the complaint investigation.

Based on record review and interview, the facility failed to completely and accurately report staff hours worked for the Payroll Based Journal (PBJ) report. This had the potential to affect all 41 residents residing in the facility. Findings include: Review of the PBJ report revealed the facility failed to have licensed nursing coverage 24 hours per day on 06/08/24, 06/09/24, 06/23/24, 06/29/24, and 06/30/24. Review of the staffing schedules for the nurses on 06/08/24, 06/09/24, 06/23/24, 06/29/24, and 06/30/24 revealed there was a licensed nurse in the facility. Interview on 11/07/24 at 9:45 A.M. with the Director of Nursing (DON) verified the corporate office stated they had trouble getting the invoices for agency staff and did not submit accurate staffing for nurses on 06/08/24, 06/09/24, 06/23/24, 06/29/24, and 06/30/24.

Based on observation, staff interviews, and facility policy review, the facility failed to complete hand hygiene during the dining room and room tray meal service. This affected two residents (Resident #25 and Resident #39) with the potential to affect all 13 residents on the skilled unit. The facility census was 41. Findings Include: 1. Observation on 11/04/24 at 12:04 P.M. revealed Certified Nursing Assistant (CNA) #356 was performing the lunch meal service in the skilled unit dining room for nine residents. CNA #356 had served the residents their drinks of choice prior to the tray cart being delivered from the kitchen. Upon receiving the tray cart in the dining room, CNA #356 began serving the trays to each resident, and assisting in preparing the food (such as removing lids to items and cutting up meat as needed) for ease of eating by the residents. After each resident was served, CNA #356 would return to the tray cart, open the cart door, remove a tray, and close the door without sanitizing or washing his hands. CNA #356 continued to serve the lunch trays until each resident in the dining room had received a lunch meal. CNA #356 then notified CNA #253 that the tray cart was ready for the room trays to be served to the residents who chose to stay in their rooms for lunch meal. Interview on 11/04/24 at 12:15 P.M. with CNA #356 revealed he did not wash his hands during lunch tray service in the dining room. CNA #356 stated washing or sanitizing his hands should have happened while the trays were being served to the residents. Review of the facility policy titled, Infection Prevention and Control, dated March 2020, revealed all staff shall wash their hands when coming on duty, between resident contacts, after handling contaminated objects, after personal protective equipment (PPE) removal, before/after eating, before/after toileting, and before going off duty. 2. Observation on 11/04/24 at 12:23 P.M. revealed Certified Nursing Assistant (CNA) #253 retrieved the tray cart from the skilled unit's dining room. CNA #253 opened the cart door, removed a lunch tray for Resident #25, knocked on the door and entered Resident #25's room. CNA #253 removed several items off the bedside table, placed the lunch tray on the bedside table, removed the lids, and exited the room. CNA #253 returned to the tray cart, opened the door, removed Resident #39's tray, closed the cart door and served Resident #39's tray without washing or sanitizing her hands. Interview on 11/04/24 at 12:40 P.M. with CNA #253 confirmed she did not wash or sanitize her hands between serving Resident #25's lunch and Resident #39's tray. CNA #253 stated she should have washed or sanitized her hands between serving the two residents their lunch tray. Review of the facility policy titled, Infection Prevention and Control, dated March 2020, revealed all staff shall wash their hands when coming on duty, between resident contacts, after handling contaminated objects, after personal protective equipment (PPE) removal, before/after eating, before/after toileting, and before going off duty.

Based on observation, record review, staff interview and facility policy review the facility failed to perform hand hygiene during medication administration. This deficient practice affected two residents (#10 and #16) out of six residents observed for infection control medication administration. The facility census was 41. Findings Include: Observation on 11/05/24 from 12:57 P.M. to 1:15 P.M. revealed Licensed Practical Nurse (LPN) #344 completing noon medications administration for residents residing on the skilled unit. LPN #344 sanitized hands prior to preparing Resident #16's narcotic medication for administration and locked the medication cart. LPN #344 then knocked on Resident #16's room door and entered the room. LPN #344 handed the medication cup to Resident #16 and Resident #16 took the medication with a drink of water. LPN #344 removed the medication and water cup from the room, returned to the medication cart and disposed of the cups in the trash can. LPN #344 then documented the administration of Resident #16's medication in Medication Administration Record (MAR). LPN #344 did not wash or sanitize hands. LPN #344 then began preparing Resident #10's medication for administration and locked the medication cart. LPN #344 then knocked on Resident #10's door and entered the room. LPN #344 handed the medication cup to Resident #10 and Resident #10 took the medication and handed the medication cup back to LPN #344. LPN #344 assisted Resident #10 with holding the water cup for Resident #10 to take a drink from. LPN #344 then left the room and returned to the medication cart and disposed of the used medication cup. LPN #344 then documented the administration of Resident #10's medication in the MAR. LPN #344 did not wash or sanitize her hands following the completion of medication administration. Review of Resident #16's medical record and physician orders revealed Resident #16 had an order dated 10/31/24 for pain medication Norco 5 milligrams (MG) - 325 MG tablet, one tablet by mouth three times per day for pain. Further review of Resident #16's MAR dated 11/04/24 revealed pain medication Norco had been administered by LPN #344. Review of Resident #10's medical record and physician orders revealed an order dated 09/05/24 for diuretic medication Lasix 40 MG, one tablet by mouth two times daily for heart failure. Further review of Resident #10's MAR dated 11/04/24 revealed diuretic medication Lasix had been administered by LPN #344. Interview on 11/05/24 at 1:20 P.M. with LPN #344 confirmed LPN #344 did not wash or sanitizer her hands before, during, or after administering medications to Resident #10 and #16. LPN #344 stated they should have washed or sanitized their hands during medication admiistration. Review of the facility policy titled, Infection Prevention and Control, dated 03/20 revealed, All staff shall wash their hands when coming on duty, between resident contacts, after handling contaminated objects, after PPE removal, before/after eating, before/after toileting, and before going off duty.

Based on record review, observation, interview, and facility policy review, the facility failed to follow physician ordered oxygen settings for administration of oxygen to residents. This affected one resident (Resident #15) out of four residents reviewed for respiratory care. The facility census was 41. Findings Include: Review of Resident #15's medical record revealed Resident #15 was admitted on [DATE] with diagnoses including respiratory disorder, dementia, and breast cancer. Resident #15 required assistance from staff for activities of daily living (ADL) tasks. Review of Resident #15's physician orders revealed an order dated 10/11/24 to administer continuous oxygen 1 to 2 liters per minute (LPM) via nasal cannula to maintain oxygen saturation (SAT) above 90 percent (%) for dependence on supplemental oxygen. Review of Resident #15's Medication Administration Record (MAR) dated 10/01/24 to 11/06/24 revealed the order dated 10/11/24 to administer continuous oxygen 1 to 2 LPM via nasal cannula to maintain oxygen SAT's above 90% for dependence on supplemental oxygen was documented as being administered with oxygen SAT recordings ranging from 90% to 97%. Observation on 11/04/24 at 10:36 A.M. revealed an oxygen concentrator located in Resident #15's room. The oxygen concentrator had a small piece of bright yellow paper taped to the top of the concentrator next to the settings observation gauge. On the piece of bright yellow paper was written 1-2 Liters. The concentrator's setting was observed to be set at 0.5 LPM. There was clear oxygen tubing connected from the oxygen concentrator to Resident #15 via a nasal cannula. Interview on 11/04/24 at 4:44 P.M. with the Director of Nursing (DON) confirmed Resident #15's oxygen concentrator setting was on 0.5 LPM's even though the physicians order for the resident was for the oxygen setting to be 1 to 2 LPM. The DON stated the physician's orders were to be followed as written. Review of the facility's policy titled, Oxygen Administration, dated June 2019, revealed oxygen was to be administered under orders of a physician, except in the case of emergency.

Based on record review, staff interview, review of infection control logs, and policy review, the facility failed to update and implement their antibiotic stewardship program policy to ensure antibiotics were ordered appropriately. This affected one (Resident #30) out of one reviewed for antibiotic use. Findings include: Review of the medical record revealed Resident #30 was admitted on [DATE] with diagnoses that included heart failure and chronic kidney disease. A progress note dated 08/14/24 at 5:40 A.M. revealed Resident #30 voiced a complaint of pressure and discomfort to bladder. Resident #30 reported feeling the need to void but unable to do so. A urine culture reported 08/15/24 revealed mixed microbiota to urine sample for Resident #30 due to possible contamination. No antibiotic sensitivity was identified. Review of the McGeer Criteria for Infection Surveillance Checklist dated 08/16/24 revealed Resident #30 had dysuria, pain, swelling, and/or tenderness. The microbiologic criteria was not met due to mixed microbiota. The checklist was marked as urinary tract infection criteria was not met. Review of the monthly infection log revealed on 08/16/24 Resident #30 had a urinary tract infection on 08/16/24 and the culture results were negative and the criteria was not met. A progress note dated 08/16/24 at 6:52 A.M. revealed orders were received to start Resident #30 on Augmentin (antibiotic) twice a day for for seven days. The Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was cognitively intact and frequently incontinent of urine. Interview on 11/06/24 at 8:34 A.M. Director of Nursing (DON) revealed the facility no longer used the Loeb Criteria, but used McGeer Criteria to determine if an infection met the criteria for an antibiotic to be administered. DON verified there were no culture results for Resident #30 on 08/16/24 to identify what antibiotic the infection was susceptible to. Review of the Antibiotic Stewardship Policy dated 06/05/22 revealed the policy was not updated to use McGeer Criteria as it stated antibiotic use protocols included the Loeb Minimum Criteria to be used to determine whether to treat any infection with antibiotics.

Based on observation, medical record review, policy review and interview, the facility failed to provide adequate care and services to prevent the development and decline of pressure ulcers. This affected three residents (#37, #87 and #91) of four residents reviewed for pressure ulcers. The facility identified three residents with pressure ulcers and the facility census was 45. Findings include: 1. Medical record review revealed Resident #87 was admitted on [DATE] with diagnoses including post-polio syndrome, hip fracture, hypertension and depression. Review of the Braden Scale for Predicting Pressure Ulcer Risk dated 01/06/24 revealed Resident #87 was at high risk for pressure ulcer/injury development. There was no risk assessment completed between 01/06/24 and 06/25/24. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #87 was cognitively intact and was not at risk for pressure ulcers. Review of the Wound Progress Report dated 05/29/24 revealed Resident #87 developed a facility acquired Stage II (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) left mid-buttock pressure ulcer that was healed on 06/12/24. Review of the Treatment Record (TAR) dated June 2024 revealed the following treatments were not completed as ordered: Barrier cream and foam dressing to left buttock daily was not completed on 06/24/24, the left buttock and left lateral ankle pressure ulcer treatment was not completed on 06/26/24. On 06/25/24 at 3:27 P.M., observation revealed Resident #87 was laying in bed on his back on a standard mattress at a 45 degree angle. The resident was partially covered with a sheet. Review of the Wound Progress Report dated 06/25/24 revealed Resident #87 had developed two facility acquired pressure ulcers including: an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the left midline buttock measuring 5.22 centimeters (cm) in length (l) by 2.8 (cm) in width (w) and the wound bed was covered with slough. The resident also had a Stage II fluid filled blister measuring 2.5 (cm) in (l) by 1.8 (cm) in (w) to the left lateral ankle. New order was received to pad and protect wound physician recommended an air mattress. On 06/26/24 at 11:55 A.M., observation revealed no evidence of a low air loss mattress on Resident #87's bed. On 06/27/24 at 12:18 P.M., observation of Resident #87's left midline buttock dressing change revealed an unstageable left midline buttock pressure ulcer approximately 6.0 (cm) in (l) by 3.0 (c) in (w). The wound was covered with necrotic (dead) tissue and the outer left buttock was dark purple in appearance. On 06/27/24 at 1:24 P.M., interview with Charge Nurse #108 verified Resident #87 did not have a Braden Risk assessment completed since 01/06/24 and these should be done every three months and with any change in skin or condition. On 06/27/24 between 2:00 P.M. and 2:11 P.M., interview with the Director of Nursing (DON) stated Resident #87 had a low air loss mattress from hospice on his bed. Observation with staff revealed no low air loss mattress on Resident #87's bed and resident was laying on his back on a regular mattress. DON asked Licensed Practical Nurse (LPN) #108 about having the specialty mattress and she stated one had been ordered two days ago but he did not have one yet. DON instructed LPN #108 to call hospice and if an air mattress could not be obtained to let her know so she can rent one for him. On 07/01/24 at 2:20 P.M., interview with the DON verified there was no evidence treatments were completed on 06/26/24, the resident did not have a low air loss mattress as recommended and was at high risk for skin breakdown. 2. Review of the record revealed Resident #37 was admitted on [DATE] with diagnoses included cerebral infarction, [NAME]-barre syndrome, arthritis, multiple myeloma, barrette's esophagus, paroxysmal atrial fibrillation and severe sepsis with septic shock. Review of the Skin Evaluation Form dated 03/28/24 revealed a pressure ulcer to the lateral left leg measuring 10.0 (cm) in (l) by 4.5 (cm) in (w) by <0.1 (cm) in depth (d). The wound edges were blackened, there was a moderate amount of serosangenous drainage. The ulcer was not staged, no interventions were documented and the assessment did not have a signature of the person completing the assessment. Review of the admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #37's cognition was moderately impaired for daily decision-making, was at risk for pressure ulcer and had no unhealed pressure, venous or arterial ulcers. Review of the Braden Scale for Predicting Pressure Ulcer Risk dated 04/18/24 revealed Resident #37 was at risk for pressure ulcer/injury development. No other risk assessments were available for review after 04/18/24. Review of the left lateral leg (LLL) Wound Progress Reports and Treatment Record (TAR) dated June 2024 revealed the following: Dated 06/05/24, the wound measured 1.26 centimeters (cm) in width (w) by 3.14 (cm) in length (l) by 0.11 (cm) in depth (d). Treatment orders included to cleanse the wound with saline solution and pat dry with gauze. Apply Tetracyte to the wound bed, followed by oil emulsion gauze and alginate. Cover with ABD pad and wrap with Kerlix followed by ACE bandage 3 times weekly and as needed (PRN) and apply silver nitrate to hypergranulated tissue. Follow up in one week. Review of Resident #37's TAR revealed the wound treatment was not completed on 06/07/24. Dated 06/12/24, the wound was covered in 100% granulation (healthy) tissue and measured 2.59 (cm) in (w) by 2.49 (cm) in (l) by 0.11 (cm) in (d). The debridement area was cleansed with saline solution then dressed with a non-adherent dressing. The clinician reviewed the importance of off loading. turning, repositioning and dressing change and frequency to help achieve wound healing. Treatment orders included to cleanse the wound with saline solution and pat dry with gauze. Apply oil emulsion gauze and alginate. Cover with ABD pad and wrap with Kerlix followed by ACE bandage 3 times weekly and PRN. Apply silver nitrate to hypergranulated tissue. Review of Resident #37's TAR revealed the wound treatment was not completed on 06/17/24. Dated 06/18/24, the wound appearance was 51.01% granulation tissue and 48.99% necrotic (dead) tissue and measured 6.28 (cm) in (w) by 6.42 (cm) in (l) by 0.2 (cm) in (d). The debridement area was cleansed with wound cleanser then dressed with a non-adherent dressing, fluff and conforming gauze. The clinician reviewed the importance of off loading, turning, and repositioning and dressing change and frequency to help achieve wound healing. The clinician referred the patient to the primary care physician for further intervention to aid in cessation. Treatment order to cleanse with wound cleanser, apply Mupirocin (topical antibiotic that's used to treat small areas of bacterial skin infections), cover with a non-stick and absorbent dressing. Wrap toes to above left knee with rolled gauze and light compression bandage daily. Start Keflex (antibiotic) 250 mg per tablet daily for one week. Review of Resident #37's Physician Orders and Medication Administration Record revealed Keflex was not ordered or administered until 06/19/24. Review of Resident #37's TAR revealed the new wound order given on 06/18/24 was not written until 06/20/24 and the LLL treatment was not completed on 06/20/24, 06/22/24, 06/24/24 or 06/25/24. Dated 06/25/24, wound measured 5.68 (cm) in (l) by 5.76 (cm) in (w) by 0.1 (cm) in (d) with 100% granulation. Treatment orders included to cleanse with wound cleanser, stop Mupirocin, and cover with nonstick dressing and absorbent pad dressing daily for one week. Finish Keflex until gone. Review of Resident #37's TAR revealed LLL treatments were not completed every three days as ordered on 06/07/24 or 06/17/24. Daily LLL wound treatments were not completed daily as ordered on 06/20/24, 06/22/24, 06/24/24, 06/25/24, 06/26/24, 06/27/24 or 06/28/24. Review of the care plan: Actual Skin Breakdown LLL wound dated 04/10/24 revealed a goal for the wound to decrease in size and show improvement and interventions included to administer treatments as ordered. On 07/01/24 at 1:40 P.M., interview with Charge Nurse #124 verified the above and confirmed a decline in Resident #37's LLL wound between 06/12/24 and 06/18/24. Charge Nurse #124 stated physician orders were to be completed as ordered and any new orders were to be started that day. On 07/09/24 at 12:12 P.M., electronic mail correspondence with LPN #138 would not confirm nor deny the accuracy of the MDS information or the unsigned assessments. 3. Medical record review revealed Resident #91 was admitted on [DATE] with diagnoses including diabetes mellitus, hip fracture and manic depression. Review of the Braden Scale for Predicting Pressure Ulcer Risk dated 01/03/24 revealed Resident #91 was at risk for pressure ulcer/injury development. There was no other risk assessment completed after 01/03/24. Review of the quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making and had one unstageable pressure ulcer. Review of Resident #91's Skin Evaluation Forms revealed the following: Dated 01/26/24, development of a suspected deep tissue injury (SDTI), soft mushy heel and area was light purple in color. Interventions included to pad and protect, float heels and bilateral foot pillows. The SDTI measured 4.5 (cm) in (l) by 5.0 (cm) in (w). Dated 01/30/24, SDTI declined to an unstageable pressure ulcer of the left heel with eschar (black, dead) noted measuring 4.0 (cm) in (l) by 5.5 (cm) in (w) by 0.1 (cm) in (d). The assessment indicated edema was present and did not indicate the amount of eschar covering the wound. Treatment was to pad and protect with ABD and Kerlix three times a week. Review of the TAR dated February 2024 revealed a left heel treatment to pad and protect with ABD and Kerlix three times a week was not completed between 02/09/24 and 02/12/24 and bilateral foot pillows and float heels at all times was not documented as being done on 02/03/24, 02/09/24 to 02/12/24, 02/19/24 or 02/27/24. Review of the record revealed no evidence of vitamins or nutritional supplements were ordered for Resident #91's unstageable left heel pressure ulcer between 01/26/24 and 03/31/24. On 06/26/24 at 5:00 P.M., interview with the DON verified if there was not initials on the electronic MAR/TAR it meant it was not done. On 07/09/24 at 12:42 P.M., electronic interview with the Administrator would not confirm or deny the above information. Review of the policy: Pressure Injury Prevention and Management (revised 02/26/24) revealed the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. This deficiency represents non-compliance investigated under Complaint Number OH00154465.

Based on observation, medical record review, resident right posting review, and interview, the facility failed to ensure resident mail was delivered unopened. This affected two residents (#79 and #91) of five sampled residents. The census was 45. Findings include: Medical record review revealed Resident #79 was admitted on [DATE] and Resident #91 was admitted on [DATE]. Review of Resident #79's quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] and Resident #91's quarterly MDS assessment dated [DATE] revealed the residents were cognitively intact for daily decision-making. On 06/25/24 at 3:35 P.M., observation of the facility required postings revealed residents had the right to have mail delivered unopened. On 06/26/24 between 9:53 A.M. and 10:05 A.M., interview with Resident #79 revealed her mail was opened in May 2024 by staff without her permission. Resident #79 stated her opened mail included a retail store package, her wireless service provider bill and an advertisement. The mail was delivered to her opened and paperclipped to a facility stamped envelope. Resident #79 stated she asked Charge Nurse #108 why her mail was opened and Charge Nurse #108 stated she was told to open both her mail and the retail package. Resident #79 stated this was a violation of her rights and it made her very upset. The resident stated she does have terrible arthritis (severe hand/finger contractions) but she could still open her own mail or at least it should be delivered unopened and if she chooses to have staff assist her with opening her mail, she would be okay with that. On 06/27/24 at 9:47 A.M., interview with Resident #91 revealed staff has delivered her mail opened and she has not given the facility permission to do this. Resident #91 stated it was not their business what she gets in the mail. She has also been waiting on a package that her daughter ordered for her over two weeks ago that she has not received. On 06/27/24 at 9:55 A.M., interview with Life Enrichment Director (LED) #126 stated Resident #91's daughter had sent her a package but it was addressed to the daughter; therefore, the package was returned to sender per the Director of Nursing. LED #126 stated the facility had not informed Resident #91 or her daughter of this but would notify her today. LED #126 verified residents had the right to receive unopened mail and resident mail should only be opened when permission was given. On 06/27/24 at 10:03 A.M., interview with Charge Nurse #108 stated she has delivered mail to residents when needed and verified she had opened Resident #79's mail and retail store package. Charge Nurse #108 stated she was instructed to do so because the box sounded like there was a bottle of pills in it. Charge Nurse #108 verified she opened the package without the resident's permission. Charge Nurse #108 would not say who instructed her to open the package but verified she should have had permission before opening the resident's mail. Charge Nurse #108 stated Resident #79 was upset when this happened and the resident was very particular with her things including her mail. On 06/27/24 at 10:42 A.M., interview with Business Office Manager #166 stated she does not open resident mail or packages. This deficiency represents non-compliance investigated under Master Complaint Number OH00154718, Complaint Number OH00154465.

Based on observation, medical record review and interview, the facility failed to ensure ostomy supplies were available as ordered. This affected one of one resident (#9) residing in the facility with an ostomy. The facility census was 45. Findings include: Medical record review revealed Resident #9 was admitted on [DATE] with diagnoses including hip fracture, weakness, atrial fibrillation, constipation and colostomy. Review of the electronic Physician Orders dated 06/26/24 revealed Resident #9 was ordered to use the following ostomy supplies: [NAME] Wafer #11402 and [NAME] Bag #18182. Resident #9's ostomy wafer and ostomy bag was to be changed every three days and as needed. On 07/03/24 at 9:29 A.M., observation of Resident #9's ostomy supplies located in her closet and top dresser drawer were labeled [NAME] Wafer #11402 and Ostomy Bag #18373. Charge Nurse #138 asked Resident #9 if she could see what ostomy supplies were in use at the time of the observation, and Resident #9 raised her shirt revealing an ostomy bag #18373 attached to the wafer. Interview with Resident #9 at the time of the observation stated those are the only ones for staff to use. Resident #9 further stated that she had not had a bowel movement for two days and had not had any incontinence issues. Review of the care plan: Potential for bowel incontinence related to weakness dated 06/26/24 revealed a goal to have fewer incontinence episodes as evidence by STNA documentation. There was no mention of the resident's ostomy and no interventions related to what supplies to use or how often to care for the site. Review of the record revealed no evidence of a care plan related to Resident #9's colostomy. On 07/03/24 at 9:27 A.M. and 9:34 A.M., observation with Charge Nurse #138 verified the resident was not using the physician ordered size ostomy bag and stated the facility did not have the size ordered. Charge Nurse #138 stated the resident had been discharged home and returned the same day and did not bring back her ostomy supplies. Charge Nurse #138 verified the resident was readmitted on [DATE] and had been using ostomy bag #18373 since readmission. This deficiency represents non-compliance investigated under Complaint Number OH00154465.

Based on medical record review, policy review and interview, the facility failed to obtain weights as ordered. This affected one resident (#37) of six sampled residents. The census was 45. Findings include: Medical record review revealed Resident #37 was admitted on [DATE] with diagnoses included cerebral infarction, [NAME]-barre syndrome, arthritis, multiple myeloma, barrett's esophagus paroxysmal atrial fibrillation, severe protein calorie malnutrition, and severe sepsis with septic shock. Review of the admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #37's cognition was moderately impaired for daily decision-making, was at risk for pressure ulcer development, and had no unhealed pressure, venous or arterial ulcers. Review of the Nutritional assessment dated [DATE] revealed Resident #37 had a clinically significant weight loss of 18% prior to admission to the facility with severe protein calorie malnutrition. Weights were to be monitored. Review of the electronic Physician Orders dated 04/04/24 revealed daily weights were ordered and Dietitian #186's Interdisciplinary Notes dated 05/09/24 revealed Resident #37's weight was stable at 151.9 pounds (lbs) with a body mass index of 23. Review of the Vital Stats dated 06/01/24 Thru 07/01/24 revealed Resident #37's weight on 06/15/24 was 148 lbs. and on 07/01/24 his weight was 149.1 lbs. Review of Resident #37's Treatment Record and Weight Tracker dated 06/01/24 through 07/01/24 revealed daily weights were not completed as ordered except on 06/09/24, 06/15/24, 06/17/24, 06/23/24, 06/24/24, 06/30/24 and 07/01/24. Review of the care plan: Vital Parameters dated 04/18/24 revealed to obtain weights as ordered. On 07/03/24 at 10:14 A.M., interview with Dietitian #186 verified Resident #37 was ordered daily weights, weights were to be documented in the electronic record and it was her expectation for physician orders to be followed. This deficiency represents non-compliance investigated under Complaint Number OH00154465.

Based on medical record review and staff and resident interviews, the facility failed to ensure their pharmacy services provided resident intravenous medication in a timely manner. This affected one resident (#45) of two residents reviewed for intravenous medication administration. The census was 45. Findings include: 1. Medical record review revealed Resident #45 was admitted on [DATE] with diagnoses including cerebral infarction, bacteremia and sepsis. Review of the Physician Orders dated 05/27/24 revealed to administer Ceftriaxone (antibiotic) 2 grams (g) intravenous (IV) every 12 hours for infection through 06/28/24. Review of the Medication Administration Record (MAR) dated June 2024 revealed the following IV antibiotics were not administered as ordered: Ceftriaxone 2 g IV was not administered upon rising on 06/08/24, 06/10/24, 06/19/24, 06/23/24 and 06/24/24. Ampicillin 2 g IV for bacteremia was not administered at 12 noon on 06/19/24 and 06/20/24. Ceftriaxone 2 g IV was not administered in the evening on 06/19/24. Review of Resident #45's Interdisciplinary Notes dated 06/24/24 at 4:32 P.M. revealed the certified nurse practitioner (CNP) was notified of four missed doses of Ceftriaxone intravenous and ordered to extend the order by four doses due to the same. Review of the Medication Incident Reporting (MIR) dated 06/24/24 revealed Ceftriaxone 2 g IV was not administered as ordered due to pharmacy did not deliver medication on 06/21/24, 06/22/24, 06/23/24 or 06/24/24. Review of the electronic mail dated 06/24/24 revealed the Director of Nursing informed pharmacy of concerns related to inability to receive needed supplies and medications. This weekend we experienced not being able to get hold of pharmacy. Numerous phone calls were made all weekend. When someone did answer we were told that the antibiotic would be in the next PM run. Never came. When they called about it, the tech said it looks like it was never received but it was suppose to go out. He has missed 4 doses of his Ceftriaxone but it was suppose to go out. The resident has missed four doses of his Ceftriaxone and one dose of Ampicillin either due to no drug or no tubing. Review of the Pharmacy POD After Hours Daily Summaries revealed the following IV antibiotics were dispensed/in progress: On 06/13/24, 16 Ampicillin 2g/100ml NS and eight Ceftriaxone 2g/100ml NS were dispensed. On 06/17/24, 12 Ampicillin 2g/100ml NS and six Ceftriaxone 2g/100ml NS were in progress. On 06/19/24, 14 IV tubing sets were dispensed. On 06/20/24, 16 ampicillin 2g/100ml NS and eight Ceftriaxone 2g/100ml NS were dispensed. Review of the signed pharmacy Packaging Slips revealed the following: On 06/10/24, 12 Ampicillin 2g/100ml NS, six Ceftriaxone 2g/100ml NS and six IV tubing sets were received by facility staff. On 06/13/24, IV supplies including 14 IV tubing sets were received by facility staff. On 06/17/24, 12 Ampicillin 2g/100ml NS and six Ceftriaxone 2g/100ml NS were received by facility staff. On 07/01/24 at 9:04 A.M., interview with the Director of Nursing stated the facility was not able to administer IV medications as ordered due to not having adequate supply of the IV antibiotics and/or IV tubing. The DON stated she has reached out to pharmacy to address the issue but continues to have issues with timely delivery of medications. On 07/01/24 at 2:45 P.M., electronic interview with Pharmacy #202 revealed the pharmacy did not have signed manifests that were linked in our system for every delivery but provided the above. Typically IV medications were sent out twice per week on Monday and Thursday for refills and a weeks worth of supplies was sent out every Wednesday for refills; however, it looks like there is a record of them running out of tubing prematurely on multiple occasions. The facility should also have six vials of Ampicillin and six vials of Ceftriaxone 1gm in their IV emergency kit. This kit is replenished on request from the facility. On 07/10/24 at 10:02 A.M., electronic interview with the Administrator revealed the facility did not have a policy for pharmacy. This deficiency represents non-compliance investigated under Complaint Number OH00154465.

Based on medical record review, observation, and interview, the facility failed to maintain an accurate medical record. This affected three residents (#45, #87 and #99) of six sampled residents. The census was 45. Findings include: 1. Medical record review revealed Resident #99 was admitted on [DATE] with diagnoses including chronic atrial fibrillation, congestive heart failure and edema. Review of the hospital Discharge Instructions dated 10/18/23 revealed Resident #99 was prescribed Torsemide (diuretic) 40 mg once a day. Review of the electronic Physician's Orders dated 10/17/23 revealed to administer two tablets of Torsemide 20 mg daily. Review of the electronic Medication Administration Record (MAR) dated October 2023 revealed two different doses to administer for Torsemide. The order was transcribed on the electronic MAR as follows: 'Torsemide 20 mg by mouth once daily. Give two tablets to equal 40 mg for Essential Hypertension. 20 mg po (orally) QD (everyday)'. On 07/03/24 at 12:40 P.M., interview with the Director of Nursing verified the order for Torsemide was not clearly written as it indicated two different doses to be administered (20 mg or 40 mg) between 10/18/23 and 11/07/23. 2. Medical record review revealed Resident #45 was admitted on [DATE] with diagnoses including cerebral infarction and sepsis. Review of the Physician Orders dated 05/27/24 revealed to administer Ceftriaxone (antibiotic) 2 grams (g) intravenous (IV) every 12 hours for infection through 06/28/24. Review of the resident's Interdisciplinary Notes revealed Resident #45's antibiotic infused without difficulty at 6:20 A.M. and a second dose was documented at 5:23 P.M. as being administered. Review of the MAR dated June 2024 revealed no evidence Ceftriaxone 2 g IV was administered on 06/22/24. On 07/01/24 at 12:30 P.M., interview with the Director of Nursing verified the medication record did not indicate Ceftriaxone 2 g was administered on 06/22/24. 3. Medical record review revealed Resident #87 was admitted on [DATE] with diagnoses including post-polio syndrome, hip fracture, hypertension and depression. Review of the Interdisciplinary Notes dated 06/17/24 revealed an air mattress with bolsters from hospice was requested and a low-air loss mattress was placed on the residents bed on 06/19/24. On 06/21/24, the resident's care conference indicated a foam mattress with foam overlay was ordered in case he wanted to lay in his bed since he preferred sleeping in recliner. On 06/25/24 at 3:27 P.M., observation revealed Resident #87's was laying in bed on his back on a standard mattress at a 45 degree angle. The resident was partially covered with a sheet. Review of the Wound Progress Report dated 06/25/24 revealed Resident #87 had developed two facility acquired pressure ulcers and new orders received included a recommendation of an air mattress. On 06/27/24 between 2:00 P.M. and 2:11 P.M., interview with the DON stated Resident #87 had a low air loss mattress from hospice on his bed. Observation with staff revealed no low air loss mattress on Resident #87's bed and the resident was laying on his back on a regular mattress. DON stated she was not aware this had not been done. The DON asked LPN #108 why the specialty mattress was not in place and she stated one had been ordered two days ago but he did not have one yet. DON verified the medical record was not accurate related to the use of a specialty pressure relieving mattress. This deficiency represents incidental non-compliance investigated under Complaint Number OH00154465 and Complaint Number OH00154365.

Based on medical record review, observation, policy review, and interview, the facility failed to maintain adequate infection control practices. This affected one resident (#87) of three residents observed for pressure ulcer treatments and one resident (#25) resident observed for incontinence care. The census was 45. Findings include: 1. Medical record review revealed Resident #87 was admitted on [DATE] with diagnoses including post-polio syndrome, hip fracture, hypertension and depression. Review of the Wound Progress Report dated 06/25/24 revealed Resident #87 had developed two facility acquired pressure ulcers including an unstageable pressure ulcer to the left midline buttock measuring 5.22 centimeters (cm) in length by 2.8 (cm) in width. The wound bed was covered with slough. On 06/27/24 at 12:18 P.M., observation of Resident #87's left midline buttock pressure ulcer treatment revealed Licensed Practical Nurse (LPN) #60 gathered her supplies, washed her hands at the sink and Hospice Aide #204 rolled Resident #87 onto his right side revealing an unstageable left midline buttock pressure ulcer approximately 6.0 (cm) in (l) by 3.0 (c) in (w). The wound was covered with necrotic (dead) tissue and the outer left buttock was dark purple in appearance. LPN #60 cleansed the wound with normal saline, applied collagenese santyl with a sterile q-tip to the necrotic area of the wound, applied a 6 (cm) by 6 (cm) comfort foam border to the area, dated the dressing once and then removed her gloves. LPN #60 washed her hands at the sink and assisted Hospice Aide #204 with positioning Resident #87 up in bed laying on his back. On 06/27/24 at 12:30 P.M., interview with LPN #60 verified she did not change her gloves after cleansing the wound or during the dressing change. LPN #60 stated she thought about it but the resident just had a bath so didn't think she needed to. Review of the policy: Clean Dressing Change (revised 01/29/24) revealed it was the policy of this campus to provide wound care in a manner to decrease potential for infection and/ or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. Procedure included to perform hand hygiene and put on clean gloves. Cleanse the wound as ordered, pat dry with gauze, measure wound using disposable measuring guide, perform hand hygiene and put on clean gloves. Apply topical ointments or creams and dress the wound as ordered, protect surrounding skin as indicated with skin protectant, secure dressing and mark with initials and date. Discard disposable items and gloves into appropriate trash receptacle and perform hand hygiene. 2. Medical record review revealed Resident #25 was admitted on [DATE] with diagnoses including dementia, anxiety and depression. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was always incontinent of bowel and bladder and dependent on staff for assistance with toileting. On 07/02/24 at 10:52 A.M., observation of incontinence care revealed State tested Nurse Aide (STNA) #46 gathered supplies including disposable incontinence wipes and an incontinence product, washed hands at the sink and applied gloves. STNA #46 assisted Resident #25 from her recliner chair to a standing position with a sit-to-stand mechanical lift, placed a bedside commode behind the resident, untabbed the resident's product and allowed it to fall into the bedside commode beneath the resident. The brief was saturated with urine and loose bowel movement. STNA #46 proceeded to use multiple incontinence wipes to cleanse the resident of bowel and urine dropping them into the bedside commode. STNA #46 then grasped the clean incontinence product, applied the new incontinence product, grasped the resident's dress, pushed the bedside commode away from the resident, maneuvered the sit-to-stand lift over the resident's wheelchair, lowered the resident into the wheelchair, applied the foot pedals to the wheelchair and then removed the soiled gloves. On 07/02/24 at 11:00 A.M., interview with STNA #46 verified gloves were not changed during incontinence care. Review of the policy: Perineal Care (revised 04/14/23) revealed it is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. Procedures included setting up supplies, place waterproof pad underneath resident, cleanse, thoroughly dry, re-position resident in supine position, change gloves if soiled and continue with perineal care. This deficiency identifies non-compliance investigated at Complaint Number OH00154465.

Based on observation, medical record review, policy review, staff interview, and physician interview, the facility failed to provide services to prevent pressure ulcers for a resident admitted with no pressure ulcers. This affected one (Resident #83) of three residents reviewed for pressure ulcers. The facility identified four residents with pressure ulcers. Harm occurred to Resident #83 on 06/30/12 when the facility failed to address Resident #83's nutritional needs and open areas developed on the resident's buttock and failed to ensure appropriate treatments were initiated in a timely manner. Findings include: On 09/04/12 at 1:34 P.M., Licensed practical nurse (LPN) #4 was interviewed and asked if Resident #83 had any pressure ulcers and she indicated Resident #83 had one pressure ulcer on her coccyx. LPN #4 stated the ulcer assessment did not include information regarding what stage the ulcer was and asked Registered Nurse (RN) #8 who was standing nearby if she knew what stage the ulcer was. RN #8 used the phone and stated she checked with RN #16 and the ulcer was a Stage III (full thickness loss). Review of Resident #83's medical record revealed [DIAGNOSES REDACTED]. Resident #83 was originally admitted to the facility on [DATE] and weighed 160 pounds, had no [MEDICAL CONDITION] and no pressure ulcers. Resident #83's risk for development of pressure ulcers was assessed and was determined to be at mild risk. Resident #83 had an order for [REDACTED]. On 05/03/12 on the quarterly dietary summary, Dietary staff #13 documented Resident #83 weighed 155 pounds on 04/30/12. It indicated Resident #83 had behavioral issues and had [MEDICAL CONDITION] in her legs. Resident #83 was hospitalized [DATE] - 05/18/12. The physical assessment dated [DATE] revealed Resident #83 weighed 152.1 pounds, had no [MEDICAL CONDITION] and no ulcers. Resident #83 was assessed regarding the risk for pressure ulcer development and was assessed at low risk. Risk factors that were identified included slightly limited sensory perception, often moist skin, chairfast, slightly limited mobility, adequate nutrition, and potential problem with shear. Diet orders on re-admission included regular diet with fork cut meat and a protein supplement three times a day. On 05/21/12 a nutritional assessment was started and signed by Dietary staff #13. On 05/23/12, Dietitian #7 documented Resident #83's nutritional care plan was the same and though Resident #83's weight had slightly decreased it was still above ideal range. The note indicated intakes had decreased to 25 - 50% (from 75 - 100%). Review of May 2012 daily care records did not indicate supplements were provided according to physician orders. After Resident #83's return to the facility on [DATE], staff documented Resident #83 slept through a minimum of nine meals. On 06/08/12, a Dietary Memorandum was sent to the physician signed by Dietary staff #13 and Dietitian #7. The memo indicated the weight loss with a weight of 147 pounds on 06/06/12. It indicated staff were attempting to get Resident #83 to snack while she was awake and that she sometimes slept at meal times, especially breakfast and lunch. The physician returned the memo on 06/11/12 with recommendations to continue to monitor weight and intake. On 06/13/12, Resident #83 weighed 147.2 pounds. The daily care record did not indicate Resident #83 received supplements between 06/01/12 and 06/07/12. The remainder of June 2012, only five supplements were documented as offered at breakfast time. Documentation for supplements on 27 occasions for supplements offered at 2:00 P.M. and 8:00 P.M. indicated the supplements were not provided because Resident #83 was sleeping. Resident #83 slept during a minimum of 24 meals during June 2012. There was no documentation indicating attempts were made to replace the nutrition that was missed due to Resident #83 sleeping. On 06/26/12, staff assessed Resident #83's risk for development of pressure ulcers and documented her nutrition was adequate. The total score did not indicate any risk for development of pressure ulcers. On 06/30/12, staff documented Resident #83 had three open areas on her left buttock. The areas measured 0.3 x 0.5 x 0 (did not indicate unit of measurement), 0.3 x 0.7 x 0 and 0.3 x 0.5 x 0. None of the areas had drainage. Treatment records did not indicate the initiation of a treatment until 07/02/12 when an order was written for [MEDICATION NAME] to the left buttock that was to be changed every seven days. On 07/02/12, Dietary staff #13 documented Resident #83 had an open area to the left buttock and continue to provide supplements three times a day. It did not address that supplements were not being provided according to physician orders [REDACTED]. On 07/06/12, the open areas measured 0.3 x 0.5, 0.3 x 0.5 and 0.2 x 0.4. The treatment record indicated all the open areas had light pink drainage. The [MEDICATION NAME] was continued. On 07/11/12, Resident #83's weight had decreased to 142.2 pounds. No new nutritional interventions were attempted. On 07/14/12, decrease in size of all the open areas was documented with areas measuring 0.2 x 0.4, 0.2 x 0.2 and 0.2 x 0.3. The area which measured 0.2 x 0.2 had documentation the wound had a dark center and it looked like a scab was forming. On 07/18/12 an order was received for Lamiseptic ointment to the buttocks twice a day. On 07/19/12, Dietitian #7 documented efforts to promote healing of the open area on the buttock had included pro-cal supplements three times a day (only documented protein supplement offered three times in July). Dietitian #7 recommended a therapeutic multiple vitamin and mineral supplement every day and indicated she would monitor intakes, weight and healing. On 07/24/12, only the open area that had the dark center on 07/14/12 remained and measured 1.2 x 1.5 x 0.4 and had documentation "dark center moist". The treatment was changed to apply Silva Killagen every day and cover with a Mepore dressing. On 07/30/12, staff documented an open area to the coccyx measuring 0.7 centimeters (cm) x 2 cm x 0.8 cm. There was no description of the wound bed or any other information available. The treatment was changed to apply [MEDICATION NAME] to the wound bed and cover with [MEDICATION NAME] and change every three to four days. July 2012 daily care records revealed Resident #83 slept through a minimum of 25 meals and also refused meals at times. August 2012 daily care records indicated of the 79 times supplements were recorded, Resident #83 slept 18 times and slept during 28 meals. There was no indication there were provisions made to attempt to replace the nutrition Resident #83 was missing. On 08/02/12, an air mattress was applied to the bed. On 08/05/12, the ulcer had increased in size to 1.4 x 1.8 x 1.8. The assessment did not include documentation of the appearance of the wound bed. On 08/07/12 the treatment was changed. The ulcer had shown signs of improvement but the assessments remained incomplete until an assessment was requested by the survey team on 09/10/12 and measurements were provided measuring 0.8 cm x 1 cm x 1 cm. The assessment indicated the ulcer bed was pink and moist. Resident #83 continued to lose weight through 08/15/12 when she weighed 139.1 pounds. There was no indication the dietitian had addressed the weight loss, poor meal intakes or supplement intakes or assessed information regarding the ulcer as the remaining documentation was completed by Dietary staff #13 (dietary manager). On 08/17/12 the Dietary Manager sent a Dietary Memo to the physician which indicated the resident's weight. The memo indicated the dietary average was 50% and intake had decreased, listed the diet order and indicated staff continued to provide breakfast or at least a supplement early in the morning when the resident was awake. The memo was returned on 08/21/12 with recommendations to continue to monitor. On 09/06/12 at 8:19 A.M. and 9:16 A.M. while other residents were in the dining room eating, Resident #83 was observed lying in bed with her eyes closed. Resident #83 was lying on her right side. At 10:45 A.M., Resident #83 remained lying in bed but was lying on her left side. Her eyes remained closed. At 11:20 A.M. and 12:10 P.M., Resident #83 was lying in bed on her right side in bed with her eyes closed. At 2:00 P.M., Resident #83 was observed sitting in the dining room and her daughter was feeding her. On 09/06/12 at 12:58 P.M., Registered nurse (RN) #16 was interviewed and stated the open areas on buttocks labeled #1 and #3 on the treatment record for 6/30/12 were not pressure related and #2 was on the coccyx but was not determined to be pressure until 07/14/12. RN #16 verified there was no documentation indicating Resident #83 received supplements in July 2012 as ordered. RN #83 stated "I don't know what to tell you". RN #16 verified the stage of the ulcer could only be found in the office on the wound tracking form. RN #16 stated staff were originally using [MEDICATION NAME] according to the standing orders and the use of the [MEDICATION NAME] started 07/02/12, not when the original open areas were observed. RN #16 verified that although the 07/14/12 assessment indicated the wound had a dark center that looked like a scab, the treatment remained a [MEDICATION NAME] and staff were assessing the wound as a Stage II (superficial). RN #16 verified the ulcer increased in size between 07/14/12 and 07/24/12 before the treatment was changed. RN #16 verified although the 07/24/12 assessment indicated the ulcer continued to have a dark center, it continued to be assessed as a Stage II ulcer and the ulcer increased in size between 07/24/12 and 07/30/12 before it was assessed as a Stage III (full tissue thickness loss). RN #16 stated the dietitian was contractual and usually visited the facility once a week. RN #16 stated the dietitian was referred to see residents with pressure ulcers and that after staff identified Resident #83 had a pressure ulcer the dietitian was consulted. RN #16 stated the dietitian was not usually consulted regarding other skin impairment. RN #16 stated when the ulcer was not healing, the wound clinic was consulted after 07/30/12 and gave recommendations for the treatment of [REDACTED]. On 09/06/12 at 11:25 A.M., State tested nursing assistant (STNA) #23 was interviewed and stated Resident #83 slept a lot and needed fed during meals. STNA #23 stated when the daughter visited she usually fed Resident #83. STNA #23 stated Resident #83 received supplements with breakfast and at 2:00 P.M. and that her appetite varied. When asked if Resident #83 was awakened to give supplements, STNA #23 stated that sometimes if the daughter was at the facility she would wake the resident to give her the supplements. On 09/06/12 at 4:49 P.M., Dietary staff #13 was interviewed and stated she was not sure why the dietitian was not consulted on all open skin areas instead of just pressure ulcers. Dietary staff #13 stated she did have the dietitian's phone number available if she wished to contact her for consultation or concerns. When Resident #83's intakes and documentation that she was sleeping through at least some meals was noted to be a pattern, Dietary staff #13 was asked what provisions had been made to meet Resident #83's nutritional needs and aid in wound healing since she was missing meals, Dietary staff #13 stated staff gave Resident #83 a supplement early in the morning if she was awake and that if dietary was at the facility before Resident #83 laid down staff would sometimes request an early breakfast. When asked if supplements that staff were providing would contain the same nutritive value as missed meals, Dietary staff #13 stated the supplements offered would not always contain the same nutritive or similar nutritive value as the missed meals. On 09/06/12 at 5:02 P.M., Dietitian #7 was interviewed and stated Dietary staff #13 had recently made a list of residents with impaired skin integrity and that she charted on them monthly. Dietitian #7 stated she usually recommended a multivitamin for residents with open areas, especially if intake was less than 100%. Dietitian #7 stated she usually did not recommend [MEDICATION NAME] or [MEDICATION NAME] levels unless a resident was in an acute care setting but instead monitored nutritional status by looking at supplements and weights. When Resident #83's intakes and progression of open areas to a Stage III ulcer since the dietitian last charted on her were discussed, Dietitian #7 stated she should have double checked on the resident, verifying she had not reviewed the nutritional status of Resident #83 since 07/19/12. Dietitian #7 stated when reviewing residents' nutritional status, she usually reviewed notes, care conferences and intakes but did not necessarily see residents. Dietitian #7 stated she did not know if the facility had a good system to notify her when pressure ulcers got worse and stated she should have kept up more with Resident #83 but was not aware she had a pressure ulcer that had progressed to a Stage III or that Resident #83 had lost more weight. Dietitian #7 stated she was not sure why she would not have been notified or consulted with regarding Resident #83's nutritional needs to aid in healing of the ulcer. On 09/07/12 at 11:44 A.M., RN #5 was interviewed and stated she spoke to RN #16 and from 06/30/12 to 07/02/12 staff did not document treatment to buttocks because the open areas were superficial and staff used the zinc based ointment they use for incontinence. RN #16 stated the facility did not have a policy and procedure related to poor oral intake. On 09/07/12 at 1:55 P.M., the Director of Nursing (DON) and Administrator were notified of concerns related to Resident #83's nutrition and pressure ulcers and avoidability. No immediate responses were provided. On 09/10/12 at 2:45 P.M., Physician #17 was interviewed and stated he was not sure he was made aware Resident #83 was sleeping through meals with the frequency staff were documenting she was. Physician #17 stated if he had known he would have looked at the medicine closely to make sure she was not over-sedated. Physician #17 stated he did not always review the pressure ulcer assessments but the nurse informed him of the wound during rounds. When asked why [MEDICATION NAME] was considered appropriate for the ulcer when it was documented with a scabbed appearance, Physician #17 stated he was not sure if he had been made aware the ulcer had a scabbed appearance so he was unable to answer why the [MEDICATION NAME] was considered appropriate at that time. On 09/11/12 at 9:30 A.M., the DON was interviewed and was asked since the facility had started transitioning to resident centered care and residents were permitted to sleep through meals, if staff had been educated regarding meeting nutritional needs. The DON stated he was unsure if education regarding nutrition in relation to residents sleeping had been addressed and would have to check. The DON stated all the staff knew there was food available for residents who needed it.

Based on medical record review, policy review, medical director report review and staff interview, the facility failed to ensure adequate supervision of residents (Resident #63 and Resident #85). This affected one resident reviewed for accidents (Resident #63) and one resident reviewed for medication use (Resident #85). Harm resulted to Resident #63 when the facility failed to provide adequate supervision of a resident assessed as a high risk for falls, failed to implement an alarm as care planned, and failed to implement appropriate fall interventions. Resident #63 had five falls, two with minor injuries and one major injury including an in-house, right hip fracture. Findings include: 1. Medical record review revealed Resident #63 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment (dated 08/11/11) revealed Resident #63 was moderately impaired for daily decision making, required extensive assist of staff for transfers and walking in room, and limited assist with toilet use. The resident's balance during transitions and walking was not steady, but the resident was able to stabilize without human assistance, and had sustained a fall in past two to six months with injury (except major injury). Review of the Care Area Assessment Summary (dated 08/11/11) revealed Resident #63 was at risk for falls related to could only see shadows due to impaired vision, was legally blind, was moderately impaired for daily decision making due to [DIAGNOSES REDACTED]. Review of the Potential for Falls care plan (dated 08/03/11) revealed interventions that included: may use personal alarms for safety, adaptive devices in reach and a monitor alarm to the bed and chair. Review of the Nurse's Notes and Falls Prevention/Management Plan for Resident #63 revealed the following: -On 08/11/11, the resident was found on the bathroom floor. The fall resulted in an ecchymotic area to the top of her head that measured 3.0 centimeters (cm) in length by 3.0 cm in width. The resident's urine was negative for infection and no other interventions were implemented. -On 09/18/11, the resident was up in the room unattended and fell over the end of the bed. The resident complained of right rib discomfort. The resident was encouraged to "hurry less" when performing self-care. -On 01/23/12, the resident was found in her room on her knees on the floor. Resident stated she was weak and complained of vertigo. The resident was encouraged to use the call light when feeling weak. -On 03/11/12, the resident fell when reaching for her walker and sat down on the floor. The resident was encouraged to call for assistance with bathroom transfers. -On 05/09/12, the resident slipped on carpet in her room, hitting her head and right rib cage. The resident was evaluated by therapy and footwear evaluated. -On 05/26/12, the resident was found lying supine on the bathroom floor with her right lower extremity externally rotated with a bulging prominence at trochantor area. Resident #63 was sent to the emergency room for evaluation and diagnosed with [REDACTED]. Review of the medical record revealed no documented evidence Resident #63 had a chair or bed monitor in place at the time of the falls on 08/11/11, 09/18/11, 01/23/12, 03/11/12, 05/09/12 and 05/26/12 as care planned. Review of the Post-Fall Investigations (dated 08/11/11, 09/18/11, 01/23/12, 03/11/12, and 05/09/12) for Resident #63 revealed no documented conclusions of the falls. Review of the medical record revealed no documented evidence of a non-compliance care plan for Resident #63. Review of the Falls Prevention/Management Protocol (undated) revealed the charge nurse was to immediately implement new measures to maintain the residents safety. Review of the Butterfly Safety Policy (dated August 2001) revealed high risk residents for falls had a butterfly emblem placed on their name tag on their door and staff was expected to observe for resident safety issues. Review of the medical director report (dated May 2012) revealed no fractures resulted from any resident falls. On 09/06/12 at 11:20 A.M., interview with State tested Nurse Aide (STNA) #11 revealed Resident #63 was allowed up in her room, asked for assistance if she needed it, and liked to be in her room. On 09/07/12 at 11:06 A.M., interview with Registered Nurse (RN) #14 stated the resident liked to be independent, and got up by herself in her room even when given reminders related to her [DIAGNOSES REDACTED].#14 had falls prior to her fracture on 05/26/12 and there was no documented evidence the care planned intervention for a bed and chair monitor was in place at the time of the falls dated 08/11/11, 09/18/11, 01/23/12, 03/11/12, 05/09/12 and 05/26/12. On 09/07/12 at 11:28 A.M., interview with STNA #26 verified Resident #63 continued to attempt to get up unassisted and has had an alarm to the chair initiated for less than a month. On 09/06/12 at 2:56 P.M., interview with the Director of Nursing (DON) and RN #14 verified Resident #63 was a high fall risk, had no documented evidence of alarms in place when the resident fell on [DATE], 09/18/11, 01/23/12, 03/11/12, 05/09/12 and 05/26/12 as care planned, and no documentation a personal alarm was used for safety. RN #14 stated alarms were not used to promote and keep the resident as independent as possible. RN #14 also verified the care plan was revised on 11/21/11, 3/08/12, 5/10/12 and the interventions that included may use personal alarm for safety and monitor to bed and chair was an active intervention for Resident #63 at the time of the falls dated 08/11/11, 09/18/11, 01/23/12, 03/11/12, 05/09/12 and 05/26/12. On 09/10/12 at 10:23 A.M., observation of Resident #63's door name label revealed a butterfly sticker. At the time of the observation, interview with STNA #25 stated residents with a butterfly sticker on the door name label indicated the resident needed to be watched closely and were at high risk for falls. On 09/10/12 at 7:40 A.M., interview with RN #14 verified interventions of call light/encourage to call for help after the falls on 09/18/11, 01/23/12 and 03/13/12 were previous interventions attempted, the resident was forgetful, cognition was impaired and varied throughout the day. 2. On 9/06/12 at 8:47 A.M., Resident #85 was observed sitting in her wheelchair at the dining room table eating her breakfast. She had two cups with lids on them and a astrodome cup with a lid and straw in it, sitting in front of her. Resident #85 was drinking from the straw. Resident #85's medical record was reviewed. She was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. At 8:55 A.M., LPN #15 verified Resident #85 had a straw in a cup containing her supplement and she was not to be using any straws to drink with. On 9/07/12 at 9:45 A.M., Resident #85 was resting in bed with her eyes closed. She had a large cup/pitcher of water on the stand next to her recliner chair that had a big straw in it. At 9:46 A.M., Registered Nurse #16 verifies there was a straw in the cup in Resident #85's room. She stated the resident was not supposed to have any straws so the straw was removed. Review of September 2012 physician orders [REDACTED]. Speech therapy notes revealed that Resident #85 was at increased risk for aspiration of her food and liquids due to her difficulty swallowing and using a straw to drink liquids made the risk even higher.

Based on observation, medical record review, staff interview, review of a Diet manual, interview of the dietitian and physician interview, the facility failed to address a resident's nutritional needs who was sleeping through meals and to ensure supplements were provided according to physician orders, and ensure interventions which the dietitian assessed would be beneficial were communicated to the physician. This affected three (Residents #10, #83, and #123) of five residents reviewed for nutrition. The census was 93. Harm occurred to Resident #83 on 06/30/12 when the facility had failed to address Resident #83's weight loss, sleeping through meals and failure to provide supplements as ordered and the resident developed impaired skin integrity. Findings include: 1. Review of Resident #83's medical record revealed [DIAGNOSES REDACTED]. Resident #83 was originally admitted to the facility on [DATE] and weighed 160 pounds, had no [MEDICAL CONDITION] and no pressure ulcers. Resident #83's risk for development of pressure ulcers was assessed and was determined to be at mild risk. Resident #83 had an order for [REDACTED]. On 05/03/12 on the quarterly dietary summary, Dietary staff #13 documented Resident #83 weighed 155 pounds on 04/30/12. It indicated Resident #83 had behavioral issues and had [MEDICAL CONDITION] in her legs. Resident #83 was hospitalized [DATE] - 05/18/12. The physical assessment dated [DATE] revealed Resident #83 weighed 152.1 pounds, had no [MEDICAL CONDITION] and no ulcers. Resident #83 was assessed regarding the risk for pressure ulcer development and was assessed at low risk. Risk factors that were identified included slightly limited sensory perception, often moist skin, chairfast, slightly limited mobility, adequate nutrition, and potential problem with shear. Diet orders on re-admission included regular diet with fork cut meat and a protein supplement three times a day. On 05/21/12 a nutritional assessment was started and signed by Dietary staff #13. On 05/23/12, Dietitian #7 documented Resident #83's nutritional care plan was the same and though Resident #83's weight had slightly decreased it was still above ideal range. The note indicated intakes had decreased to 25 - 50% (from 75 - 100%). Review of May 2012 daily care records did not indicate supplements were provided according to physician orders. After Resident #83's return to the facility on [DATE], staff documented Resident #83 slept through a minimum of nine meals. On 06/08/12, a Dietary Memorandum was sent to the physician signed by Dietary staff #13 and Dietitian #7. The memo indicated the weight loss with a weight of 147 pounds on 06/06/12. It indicated staff were attempting to get Resident #83 to snack while she was awake and that she sometimes slept at meal times, especially breakfast and lunch. The physician returned the memo on 06/11/12 with recommendations to continue to monitor weight and intake. On 06/13/12, Resident #83 weighed 147.2 pounds. The daily care record did not indicate Resident #83 received supplements between 06/01/12 and 06/07/12. The remainder of June 2012, only five supplements were documented as offered at breakfast time. Documentation for supplements on 27 occasions for supplements offered at 2:00 P.M. and 8:00 P.M. indicated the supplements were not provided because Resident #83 was sleeping. Resident #83 slept during a minimum of 24 meals during June 2012. There was no documentation indicating attempts were made to replace the nutrition that was missed due to Resident #83 sleeping. On 06/26/12, staff assessed Resident #83's risk for development of pressure ulcers and documented her nutrition was adequate. The total score did not indicate any risk for development of pressure ulcers. On 06/30/12, staff documented Resident #83 had three open areas on her left buttock. The areas measured 0.3 x 0.5 x 0 (did not indicate unit of measurement), 0.3 x 0.7 x 0 and 0.3 x 0.5 x 0. None of the areas had drainage. Treatment records did not indicate the initiation of a treatment until 07/02/12 when an order was written for [MEDICATION NAME] to the left buttock that was to be changed every seven days. On 07/02/12, Dietary staff #13 documented Resident #83 had an open area to the left buttock and continue to provide supplements three times a day. It did not address that supplements were not being provided according to physician orders [REDACTED]. On 07/06/12, the open areas measured 0.3 x 0.5, 0.3 x 0.5 and 0.2 x 0.4. The treatment record indicated all the open areas had light pink drainage. The [MEDICATION NAME] was continued. On 07/11/12, Resident #83's weight had decreased to 142.2 pounds. No new nutritional interventions were attempted. On 07/14/12, decrease in size of all the open areas was documented with areas measuring 0.2 x 0.4, 0.2 x 0.2 and 0.2 x 0.3. The area which measured 0.2 x 0.2 had documentation the wound had a dark center and it looked like a scab was forming. On 07/18/12 an order was received for Lamiseptic ointment to the buttocks twice a day. On 07/19/12, Dietitian #7 documented efforts to promote healing of the open area on the buttock had included pro-cal supplements three times a day (only documented protein supplement offered three times in July). Dietitian #7 recommended a therapeutic multiple vitamin and mineral supplement every day and indicated she would monitor intakes, weight and healing. On 07/24/12, only the open area that had the dark center on 07/14/12 remained and measured 1.2 x 1.5 x 0.4 and had documentation "dark center moist". The treatment was changed to apply Silva Killagen every day and cover with a Mepore dressing. On 07/30/12, staff documented an open area to the coccyx measuring 0.7 centimeters (cm) x 2 cm x 0.8 cm. There was no description of the wound bed or any other information available. The treatment was changed to apply [MEDICATION NAME] to the wound bed and cover with [MEDICATION NAME] and change every three to four days. July 2012 daily care records revealed Resident #83 slept through a minimum of 25 meals and also refused meals at times. August 2012 daily care records indicated of the 79 times supplements were recorded, Resident #83 slept 18 times and slept during 28 meals. There was no indication there were provisions made to attempt to replace the nutrition Resident #83 was missing. On 08/02/12, an air mattress was applied to the bed. On 08/05/12, the ulcer had increased in size to 1.4 x 1.8 x 1.8. The assessment did not include documentation of the appearance of the wound bed. On 08/07/12 the treatment was changed. The ulcer had shown signs of improvement but the assessments remained incomplete until an assessment was requested by the survey team on 09/10/12 and measurements were provided measuring 0.8 cm x 1 cm x 1 cm. The assessment indicated the ulcer bed was pink and moist. Resident #83 continued to lose weight through 08/15/12 when she weighed 139.1 pounds. There was no indication the dietitian had addressed the weight loss, poor meal intakes or supplement intakes or assessed information regarding the ulcer as the remaining documentation was completed by Dietary staff #13 (dietary manager). On 08/17/12 the Dietary Manager sent a Dietary Memo to the physician which indicated the resident's weight. The memo indicated the dietary average was 50% and intake had decreased, listed the diet order and indicated staff continued to provide breakfast or at least a supplement early in the morning when the resident was awake. The memo was returned on 08/21/12 with recommendations to continue to monitor. On 09/06/12 at 8:19 A.M. and 9:16 A.M. while other residents were in the dining room eating, Resident #83 was observed lying in bed with her eyes closed. Resident #83 was lying on her right side. At 10:45 A.M., Resident #83 remained lying in bed but was lying on her left side. Her eyes remained closed. At 11:20 A.M. and 12:10 P.M., Resident #83 was lying in bed on her right side in bed with her eyes closed. At 2:00 P.M., Resident #83 was observed sitting in the dining room and her daughter was feeding her. On 09/06/12 at 12:58 P.M., Registered nurse (RN) #16 was interviewed and stated the open areas on buttocks labeled #1 and #3 on the treatment record for 6/30/12 were not pressure related and #2 was on the coccyx but was not determined to be pressure until 07/14/12. RN #16 verified there was no documentation indicating Resident #83 received supplements in July 2012 as ordered. RN #16 stated "I don't know what to tell you". RN #16 verified the stage of the ulcer could only be found in the office on the wound tracking form. RN #16 stated staff were originally using [MEDICATION NAME] according to the standing orders and the use of the [MEDICATION NAME] started 07/02/12, not when the original open areas were observed. RN #16 verified that although the 07/14/12 assessment indicated the wound had a dark center that looked like a scab, the treatment remained a [MEDICATION NAME] and staff were assessing the wound as a Stage II (superficial). RN #16 verified the ulcer increased in size between 07/14/12 and 07/24/12 before the treatment was changed. RN #16 verified although the 07/24/12 assessment indicated the ulcer continued to have a dark center, it continued to be assessed as a Stage II ulcer and the ulcer increased in size between 07/24/12 and 07/30/12 before it was assessed as a Stage III (full tissue thickness loss). RN #16 stated the dietitian was contractual and usually visited the facility once a week. RN #16 stated the dietitian was referred to see residents with pressure ulcers and that after staff identified Resident #83 had a pressure ulcer the dietitian was consulted. RN #16 stated the dietitian was not usually consulted regarding other skin impairment. RN #16 stated when the ulcer was not healing, the wound clinic was consulted after 07/30/12 and gave recommendations for the treatment of [REDACTED]. On 09/06/12 at 11:25 A.M., State tested nursing assistant (STNA) #23 was interviewed and stated Resident #83 slept a lot and needed fed during meals. STNA #23 stated when the daughter visited she usually fed Resident #83. STNA #23 stated Resident #83 received supplements with breakfast and at 2:00 P.M. and that her appetite varied. When asked if Resident #83 was awakened to give supplements, STNA #23 stated that sometimes if the daughter was at the facility she would wake the resident to give her the supplements. On 09/06/12 at 4:49 P.M., Dietary staff #13 was interviewed and stated she was not sure why the dietitian was not consulted on all open skin areas instead of just pressure ulcers. Dietary staff #13 stated she did have the dietitian's phone number available if she wished to contact her for consultation or concerns. When Resident #83's intakes and documentation that she was sleeping through at least some meals was noted to be a pattern, Dietary staff #13 was asked what provisions had been made to meet Resident #83's nutritional needs and aid in wound healing since she was missing meals, Dietary staff #13 stated staff gave Resident #83 a supplement early in the morning if she was awake and that if dietary was at the facility before Resident #83 laid down staff would sometimes request an early breakfast. When asked if supplements that staff were providing would contain the same nutritive value as missed meals, Dietary staff #13 stated the supplements offered would not always contain the same nutritive or similar nutritive value as the missed meals. On 09/06/12 at 5:02 P.M., Dietitian #7 was interviewed and stated Dietary staff #13 had recently made a list of residents with impaired skin integrity and that she charted on them monthly. Dietitian #7 stated she usually recommended a multivitamin for residents with open areas, especially if intake was less than 100%. Dietitian #7 stated she usually did not recommend [MEDICATION NAME] or [MEDICATION NAME] levels unless a resident was in an acute care setting but instead monitored nutritional status by looking at supplements and weights. When Resident #83's intakes and progression of open areas to a Stage III ulcer since the dietitian last charted on her were discussed, Dietitian #7 stated she should have double checked on the resident, verifying she had not reviewed the nutritional status of Resident #83 since 07/19/12. Dietitian #7 stated when reviewing residents' nutritional status, she usually reviewed notes, care conferences and intakes but did not necessarily see residents. Dietitian #7 stated she did not know if the facility had a good system to notify her when pressure ulcers got worse and stated she should have kept up more with Resident #83 but was not aware she had a pressure ulcer that had progressed to a Stage III or that Resident #83 had lost more weight. Dietitian #7 stated she was not sure why she would not have been notified or consulted with regarding Resident #83's nutritional needs to aid in healing of the ulcer. On 09/07/12 at 8:41 A.M., Licensed practical nurse (LPN) #27 was interviewed and stated Resident #83 was sometimes up at night but it varied. LPN #27 stated they had tried to give Resident #83 meals in the past when she was awake at night but found that she was more interested in moving around. LPN #27 stated staff had access to the kitchen with leftovers and supplies to make sandwiches so finger foods could be offered but that was generally not what staff offered. LPN #27 stated staff did offer Boost and nutrigrain bars at times but had little success with getting Resident #83 to accept them but Resident #83 would usually eat some cookies and drink soda. LPN #27 stated Resident #83 did a lot of walking which burned a lot of calories. On 09/07/12 at 11:44 A.M., RN #5 was interviewed and stated the facility did not have a policy and procedure related to poor oral intake. On 09/07/12 at 1:55 P.M., the Director of Nursing (DON) and Administrator were notified of concerns related to Resident #83's nutrition and pressure ulcers and avoidability. No immediate responses were provided. On 09/10/12 at 2:45 P.M., Physician #17 was interviewed and stated he was not sure he was made aware Resident #83 was sleeping through meals with the frequency staff were documenting she was. Physician #17 stated if he had known he would have looked at the medicine closely to make sure she was not over-sedated. On 09/11/12 at 9:30 A.M., the DON was interviewed and was asked since the facility had started transitioning to resident centered care and permitted residents to sleep through meals, if staff had been educated regarding meeting nutritional needs. The DON stated he was unsure if education regarding nutrition in relation to residents sleeping had been addressed and would have to check. The DON stated all the staff knew there was food available for residents who needed it. 2. Review of Resident #123's medical record revealed [DIAGNOSES REDACTED]. Resident #123 weighed 189.8 pounds when admitted on [DATE]. On 08/02/12 at 8:00 P.M. a nursing note indicated a state tested nursing assistant (STNA) reported Resident #123 ate one bite of sandwich, 1/2 cup of coffee and 120 juice and indicated he had [MEDICAL CONDITION] in his right hip and leg. On 08/04/12, the dietitian documented Resident #123 had a good appetite and intake. On 08/12/12, Dietary staff #13 documented that intakes were 50 - 100%. On 05/21/12. Resident #123 weighed 175 pounds and on 08/23/12 weighed 175.2 pounds. A Dietary Memorandum was sent to the physician notifying him of the weight loss. The memo was returned on 08/24/12 with recommendations to change Resident #123's diet (was no added sodium) to regular and provide a four ounce protein supplement every day. Resident #123 was hospitalized [DATE] - 09/01/12. A nutritional assessment dated [DATE] and signed by Dietary staff #13 indicated a weight of 177. The assessment indicated Resident #123 was on a regular diet with a four ounce supplement every day. Daily care records did not reveal the supplement had been started. On 09/10/12 at 10:37 A.M., state tested nursing assistant (STNA) #21 was interviewed and stated she usually did not work with Resident #123 but asked STNA #22 and stated Resident #123's appetite was fair but STNA #22 was unsure if the resident was supposed to get supplements. On 09/10/12 at 10:45 A.M., Dietary staff #13 and Registered Nurse (RN) #20 was interviewed and verified that intake of supplements was not documented. 3. Review of Resident #10's medical record revealed the resident was admitted to the facility 10/15/07 with [DIAGNOSES REDACTED]. The resident was readmitted [DATE] post [MEDICAL CONDITION]. Record review revealed on readmission Resident #10 weighed 106 pounds at a height of 62 inches and a Body Mass Index (BMI) of 19. The nutritional assessment dated [DATE] by Dietitian #7 indicated Resident #10's weight and Body Mass Index (BMI) were mildly low though stable. The assessment further indicated the resident may benefit from a multivitamin supplement daily as well as supercereal or four ounces Ensure daily. The assessment included an ideal body weight for Resident #10 would be 128-143 pounds. Laboratory testing included a total protein 7.9 grams per deciliter (g/dL), normal 6.0-8.5 g/dL, and [MEDICATION NAME] 4.2 g/dL,normal 3.2-4.8 g/dL, on 08/03/10. There was no further evidence of repeat lab test until admission to the hospital for the [MEDICAL CONDITION] 01/06/12 when the total protein was 6.6 g.dL and [MEDICATION NAME] 3.6 g/dL. The current weight of 98 pounds dropped the BMI to 18, severe nutritional depletion, since the readmission 01/10/12. There was no evidence of orders for a multivitamin, supercereal or four ounces Ensure daily. There was no documented evidence of a trial of supplements or documented percentages of supplements. Review of Resident #10's weights revealed: 09/02/11= 99.9 pounds 01/06/12 =104.6 pounds prior to hospitalization of 01/06/12-01/10/12. 01/10/12 =106 pounds on readmission. The resident had some [MEDICAL CONDITION] on 01/10/12 and was administered [MEDICATION NAME] (as needed) for [MEDICAL CONDITION] 03/02/12= 98.5 pounds 03/09/12 =96.6 pound 03/15/12= a memo to the resident's doctor was sent and revealed no change in dietary order, continue to monitor 05/25/12= 96.6 pounds 06/08/12 =95.3 pounds 07/06/12 =93.8 pounds 08/31/12= 98 pounds Review of the Body Mass Index provided by the facility from the Diet Manual 2008 indicated on page 407 a BMI of 19 or less identified severe nutritional depletion. On 09/04/12 at 3:00 P.M. interview with Licensed Practical Nurse (LPN) #6 revealed Resident #10 was not on a supplement. On 09/06/12 at 1:00 P.M. interview of LPN #10 revealed meal percentages were only documented during the MDS assessment period unless there was an issue with weight loss. LPN #10 further verified Resident #10 had a low weight but did not get meal percentages documented. On 09/06/12 at 2:50 P.M. interview of LPN #10 revealed since December 2011 she had not known Resident #10 to be on a multivitamin, receive Ensure or supercereal. On 09/06/12 at 5:20 P.M. interview with Dietitian #7 verified that she does not recommend labs for long term care. Dietitian #7 indicated she goes by the notes of the Dietary Manager to write recommendations and doesn't necessarily see the residents. Dietitian #7 indicated that she filled out the recommendation memo for the Physician and if there was none then she failed to do it. Further verified that no new interventions had been put in place. Dietitian #7 verified the multivitamin was not ordered as recommended, there was no documented evidence the resident received supercereal daily and no evidence of when, how many times and what type of Ensure supplement was trialed. Dietitian #7 verified there was no documented evidence the supercereal was being given and the percentage eaten except for the one week period of time during the MDS assessment period when meal percentages were documented. On 09/06/12 at 4:20 P.M. interview with Dietary Staff #13 revealed Resident #10 had been on supercereal from 07/09/10 to present. Further stated that she would talk to the staff about recommendations but did not recall speaking to them regarding the Dietitian's recommendations from 01/11/12. Interview revealed the Dietitian did not order laboratory work very often. Dietary staff #13 verified a 03/15/12 Dietary Memo said she did not like the supplement; however, there was no documentation that she was given a supplement and refused. She didn't recall what supplement they tried and did not know of any new measures instituted this year. Interview on 09/10/12 at 2:18 P.M. with Physician #9 verified that he did not recall being asked for a multivitamin. Physician #9 further indicated that "since it is not ordered I probably was not asked". Physician #9 further indicated that he had no knowledge of being asked for a supplement. Interview on 09/07/12 at 9:30 A.M. with RN #14 verified there was no evidence the physician was notified of the recommendation for the multivitamin because there were no orders and no evidence a Dietary Memo was generated for him to review.