Every finding on record at Whispering Hills Rehabilitation and Nursing Center

Based on record review and interview the facility failed to ensure Resident #13 and #44 received a written bed hold authorization letters and the Ombudsman was notified of all hospitalization and discharges. This affected two residents (Resident #13 and #44) of three residents reviewed for discharge planning. The facility census was 38.Findings Include: 1. Review of Resident #44 ' s medical record revealed admission date 01/05/26 and a discharge to the hospital on [DATE] with diagnoses including but not limited to chronic obstructive pulmonary disease, unspecified sequelae of cerebral infarction, dysphagia, hypertension, anxiety disorder and depression. Review of Resident #44 ' s admission Minimum Data Set (MDS) dated [DATE] revealed Resident #13 was cognitively intact with a Brief Interview Mental Status (BIMS) score of 14 out a possible 15 and required staff assistance with Activities of Daily Living (ADL) tasks. Further review revealed Resident #44 was his own representative and had a family member as an emergency contact. a. Review of Resident #44 ' s Interact Transfer assessment dated [DATE] revealed Resident #44 was transferred to the hospital for shortness of breath, diaphoretic (excessive, often cold or clammy, sweating that is not caused by heat or exercise) and panicking. Review of Resident #44 ' s progress notes dated 01/24/26 at 7:00 P.M. revealed Resident #44 came to the nurse ' s station in a panic stating he was having difficulty breathing, resident appeared diaphoretic. The physician and family were notified of the transfer. Review of the facility Bed Hold Authorization letter dated 01/24/26 revealed Resident #44 had 30 Medicaid bed hold days remaining. Resident #44 did not sign or date the bed hold authorization acknowledging the receipt of the bed hold notice. The Business Office Manager (BOM) #435 had signed and dated the form and had noted Resident #44's sister was notified of the bed old letter. Further review of the bed hold authorization letter revealed the facility must distribute copies of the completed bed hold notice at the time of transfer with the original document issued to the resident or resident representative. Interview on 02/19/26 at 12:44 P.M. with Business Office Manager (BOM) #435 confirmed Resident #44's sister had only been contacted for the bed hold authorization via telephone on 01/24/26 and a written bed hold notification was not issued to Resident #44 upon transfer to the hospital. b. Review of the Notification to Ombudsman of Resident discharge date d 02/19/26 revealed the Ombudsman had not been notified of Resident #44 ' s hospitalization on 01/24/26. Interview on 02/19/26 at 12:44 P.M. with BOM #435 verified she does not notify the Ombudsman of Resident #44's discharge to the hospital. 2. Review of Resident #13 ' s medical record revealed admission date 12/24/25 and a discharge to the hospital on [DATE] with diagnoses including but not limited to osteomyelitis, depression, unhealed pressure ulcers, and paraplegia. Review of Resident #13 ' s Medicare/5-Day Minimum Data Set (MDS) dated [DATE] revealed Resident #13 was cognitively intact with a Brief Interview Mental Status (BIMS) score of 15 out a possible 15 and required staff assistance with Activities of Daily Living (ADL) tasks. Further review revealed Resident #13 was his own representative and had a family member as an emergency contact. Review of Resident #13 ' s Interact Transfer assessment dated [DATE] revealed Resident #13 was transferred to the hospital for specific laboratory testing of blood cultures related to unhealed pressure ulcers with osteomyelitis. Review of Resident #13 ' s progress notes dated 02/03/26 12:40 P.M. revealed Resident #13 was transferred to the hospital for further laboratory testing related to unhealed pressure ulcers with osteomyelitis. The physician, resident and resident family member were notified of the hospital transfer. Review of the facility Bed Hold Authorization letter dated 02/03/26 revealed Resident #13 has 30 Medicaid bed hold days remaining. Resident #13 did not sign or date the bed hold authorization acknowledging the receipt of the bed hold notice. The Business Office Manager (BOM) #435 had signed and dated the form and had noted Resident #13 had been contacted by telephone concerning the bed hold letter. Further review of the bed hold authorization letter revealed the facility must distribute copies of the completed bed hold notice at the time of transfer with the original document issued to the resident or resident sponsor. Resident #13 remained hospitalized at the time of the onsite survey. Interview on 02/19/26 at 12:44 P.M. with BOM #435 confirmed Resident #13 had only been contacted for the bed hold authorization via telephone on 02/03/26 and a written bed hold notification was not issued to Resident #13 upon transfer to the hospital. Review of the facility ' s policy titled Bed-Holds and Returns undated revealed prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy.

Based on record review, observation, interview and facility policy review the facility failed to assist a dependent resident with fingernail care. This deficient practice affected one resident (Resident #3) out of two residents reviewed for Activities of Daily Living. The facility census was 38.Findings Include: Review of Resident #3's medical record revealed admission date 08/04/25 with diagnoses including but not limited to respiratory failure, type two Diabetes, depression, history of stroke and vascular dementia.Review of Resident #3's self-care deficit care plan dated 08/05/25 revealed Resident #3 required encouragement and assistance from staff to complete self-care tasks.Review of Resident #3's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had impaired cognition with a Brief Interview Mental Status (BIMS) score of 11 out of possible 15, used a wheelchair for mobility, and was dependent on staff for the completion of personal hygiene tasks.Review of Resident #3's shower documentation dated from 01/12/26 to 02/16/26 revealed on 01/22/26 Resident #3's fingernails had been trimmed and there were no further documentation of nails being trimmed. An observation on 02/17/26 at 10:25 A.M. revealed Resident #3 resting in bed with bilateral hands visible. Resident #3's fingernails were observed to have chipped light blue fingernail polish. All fingernails were long and had dark colored substances observed under the nails.An interview on 02/18/26 at 10:41 A.M. with Certified Nursing Assistance (CNA) #107 confirmed Resident #3 had long dirty fingernails and the staff should be assisting Resident #3 in cleaning and trimming her fingernails on a regular basis.Review of the facility's policy titled Care of Fingernails/Toenails dated 10/2010 revealed nail care includes daily cleaning and regular trimming.

Based on observation, interview, and record review the facility failed to ensure Resident #18 had audiology follow up completed. This affected one (#18) of one residents reviewed for hearing or vision concerns. The census was 38. Findings include:Record review for Resident #18 revealed an admission date of 05/16/25. Diagnoses include type II diabetes without complications, essential (primary) hypertension, peripheral vascular disease, acquired absence of right leg above knee, plasma cell leukemia having not achieved remission, solitary plasmacytoma not having achieved remission, need for assistance with personal care, adjustment disorder with mixed anxiety and depressed mood, and bilateral hypertensive retinopathy.Review of Resident #18's 360 care Audiology appointment dated 09/29/25 9:30 A.M. exam revealed Resident #18 was referred by the facility due to decreased hearing. A otoscopy was completed and it revealed impacted cerumen of both ears. Debrox (ear wax softener used to help remove wax from the ears) was recommended for cerumen management. Follow up noted as cerumen management in 1-3 months.Review of Resident #18's quarterly Minimum Data Set (MDS) 3.0 dated 01/25/26 revealed a Brief Interview for Mental Status (BIMS) score of 15. Review of Resident #18's hearing, speech, and vision, revealed Resident #18 had minimal difficulty with hearing and no hearing aids.Review of Resident #18's care plan confirmed Resident #18 has a communication deficit problem related to hearing deficit. Goal to maintain current level of communication through the review date. Interventions include being conscious of resident position when in groups, activities, dining room to promote proper communication with others, prefers communicating with the television off, monitor/document/report PRN changes in ability to communicate, refer to audiology for hearing consult as ordered.Observation on 02/17/6 at 10:16 A.M. revealed Resident #18 was pointing to their ears while attempting to communicate.Interview on 02/18/26 at 4:25 P.M. with the Social Worker confirmed Resident #18 was not scheduled for a follow-up Audiology appointment.Review of the facility's policy titled, Referral Agreements dated 10/2008 confirmed to facilitate referrals, the facility has entered into referral agreements with agencies that will provide services to residents. The scope of agencies and the agreements are consistent with the needs of the facility's resident population. Inquiries concerning the availability and use of referral agencies should be directed to social services or to administrator.

Based on observation, record review, interview and policy review the facility failed to ensure appropriate trach care was provided. This affected one resident (Resident #34) of one residents observed for trach care.Findings Include: Review of the medical record for Resident #34 revealed an admission date 02/10/26 with diagnosis including but not limited to malignant neoplasm of tongue, protein-calorie malnutrition, dysphagia, and anxiety. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #34 had intact cognition and required tracheostomy (trach) care daily. Review of the physician orders dated 02/10/26 revealed trach care per protocol and speaking/[NAME] Muir valve to trach, as tolerated cuff must be deflated on trach prior to placement of speaking valve.Observation on 02/19/26 at 1:35 P.M. of Resident #34's trach care with Registered Nurse (RN) #315 revealed during trach care RN #315 removed the speaking valve off the trach and placed it on the bed side table. RN #315 suctioned Resident #34 and placed the suction tubing on the bedside table and the end of the suction tubing fell into the clean hydrogen peroxide/normal saline solution to clean the trach area. RN #315 continued with trach care and removed the trach collar to clean under the collar, (with the hydrogen peroxide solution that the suction tubing fell into). RN #315 let go of the trach cannula and Resident #34 coughed the outer trach tube cuff out, onto Resident #34's chest. RN #315 quickly picked up the trach cannula and inserted it back into trach stoma. RN #315 then picked up the speaking valve (that had fallen on the floor) and secured it back on the trach cuff. Interview on 02/19/26 at 2:05 P.M. with RN #315 verified the above observation of the suction tubing falling into the clean solution (the suction tubing is not considered clean). RN #315 verified the outer trach cuff fell out of the trach stoma and she put it back in and did not get a new trach tube cuff. RN #315 verified she should not have put the dirty speaking valve that had fallen on the floor back on the trach cuff, she should have replaced it with a new speaking valve. Review of the facility policy Tracheostomy Care, dated August 2013 revealed aseptic technique (using sterile gloves, tools, and solutions to clean the stoma and inner cannula) must be used.

Based on record review and interview, the facility failed to ensure Resident #20 received antipsychotic medication as scheduled and per the resident's routine dose resulting in a significant medication error. This affected one (Resident #20) out of six residents reviewed for medications. The facility census was 38. Findings include: Review of the medical record revealed Resident #20 was admitted on [DATE] with diagnoses that included schizoaffective disorder bipolar type, borderline intellectual functioning, and Asperger's syndrome. A care plan dated 02/05/24 revealed Resident #20 required psychotropic/mood stabilizer medications for behavior management. Interventions included to administer psychotropic/mood stabilizer medications as ordered. A care plan dated 02/09/24 revealed Resident #20 had behavior problems with interventions that included to administer medications as ordered. A psychiatric note dated 10/01/25 revealed Resident #20 received Invega Sustenna (atypical antipsychotic) 156 milligram/milliliter (mg/ml) intramuscular (IM) injection every 28 days for schizoaffective disorder. An electronic medical administration record progress note dated 11/20/25 at 9:27 P.M. revealed Resident #20's Invega was on order. A general progress note dated 11/21/25 at 12:13 P.M. revealed Resident #20's Invega was delivered. The physician was notified and was agreeable to administering Invega 156 mg/ml one time only. (Please note, the psychiatrist who gave the initial medication order, was not contact).There was no record of administration for the resident's Invega (ordered monthly) administered in December 2025. A general progress note dated 01/11/26 at 8:10 A.M. revealed Resident #20 approached the nurse and asked about their (routine) Invega injection. The nurse called the psychiatric provider to ask about a clarification. A progress note dated 01/11/26 at 8:42 A.M. revealed the facility was awaiting a call back from psychiatric provider. The on-call medical provider was notified (not the psychiatrist), and a new order was received to administer Invega 117 mg IM one time only. The facility to contact psychiatric services for continued taper increase dose on next business day. A progress note dated 01/13/26 at 9:27 A.M. revealed Resident #20 was administered Invega 117 mg IM on 01/12/26. A general progress note dated 01/14/26 at 1:49 P.M. revealed a clarification order was received from psychiatric certified nurse practitioner. Resident #20 was to receive Invega 156 mg/ml on 01/27/26 and then every 28 days. A psychiatric progress note dated 01/14/26 revealed a facility nurse called and was uncertain why Resident #20 Invega injections was not on the MAR for December (not administered). The resident had asked about the injection, and it was discovered the dose was past due. The on-call medical doctor was notified and gave an order to administer Invega 117 mg IM. It had been more than six weeks since the last injection so Resident #20 would require an additional dose in one week. Resident #20 was scheduled to receive 156 mg/ml on 01/27/26 and then every 28 days. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #20 was cognitively intact. The resident had delusions and received antipsychotic medications. A physician order dated 01/27/26 revealed Resident #20 was ordered Invega intramuscular injection every 28 days for schizoaffective disorder. A psychiatric note dated 01/28/26 revealed Resident #20 took medication as prescribed and missed a dose of Invega. The medical team ordered a low loading dose of Invega, and an additional dose was administered one week later. Invega was discontinued by the medical provider on 11/20/25. Interview during the onsite survey was attempted with Resident #20 however the resident was unable to be interviewed due to cognition. An interview on 02/18/26 at 10:38 A.M. Director of Nursing (DON) verified Resident #20 missed a scheduled dose of Invega in December. DON stated Invega was not available on the scheduled date in November. The nurse obtained a new order so Invega could be administered when it arrived. The new order was one time only and not for every 28 days which resulted in the Invega order not being resumed monthly in December 2025, causing the omitted dose.

Based on record review, and staff interviews, the facility failed to provide required specialized rehabilitative services (speech therapy) for one of one residents reviewed (Resident #17) who was identified as needing further swallowing assessment. Findings include: Review of the medical record revealed Resident #17 was admitted on [DATE] with diagnoses including dysphagia, traumatic brain injury, schizophrenia, major depressive disorder, type II diabetes mellitus, and other chronic medical conditions.Review of the comprehensive Minimum Data Set (MDS) dated [DATE] reflected cognitive impairment.Review of the Registered Dietitian (RD #316) Weight Review dated 02/19/2026 revealed Resident #17 experienced significant weight loss. The RD documented the resident recently had teeth extracted and requested a Speech-Language Pathology (SLP) evaluation to assess swallowing function and determine if the current diet order remained appropriate. Review of physician orders and therapy documentation revealed no evidence that an SLP evaluation was completed following the RD's documented recommendation.On 02/19/2026 at 11:06 A.M., interview with Therapy Manager (TM #115) revealed therapy typically received referrals verbally from nursing staff. TM #115 confirmed the speech therapist had not seen Resident #17 since July 2025 and stated documentation would be present if an evaluation had been completed.On 02/19/2026 at 11:15 A.M., interview with Director of Nursing (DON #111) and Regional DON (#418) revealed staff enter therapy orders and verbally notify therapy when referrals are made. The DON acknowledged being unaware the SLP evaluation had not been completed for Resident #17.

Based on observation, interview, and medical record review the facility failed to ensure Resident #34 and Resident #37 had complete and accurate medical records. This affected 2 of 16 medical records reviewed. The census was 38. Finding include: Record review of Resident #34's medical record revealed an admission date of 02/10/26. Diagnoses include malignant neoplasm of tongue and mouth, dysphagia, and tracheostomy status. Review of Resident #34's comprehensive The Minimum Data Set (MDS) 3.0 dated 02/17/26 revealed a Brief Interview for Mental Status (BIMS) score of 15. Record review of Resident #34's medical record revealed an active physician order for Nothing by Mouth (NPO) diet Nothing by Mouth texture, nothing by mouth consistency dated 02/10/26. Review of Resident #34's medical record revealed a care plan stating Resident #34 has an alteration in neurological status related to dysphagia. Goals include being able to function at the fullest potential possible as outlined by the interdisciplinary team, will maintain optimal status and quality of life within limitations imposed by neurological deficits, and will free from signs and symptoms of complications of dysphagia (aspiration pneumonia and dehydration). Interventions include adjust diet to accommodate chewing, swallowing, or eating issues to maximize independence and nutritional intake, give medications as ordered, monitor intake to assure an adequate fluid intake to prevent dehydration, physical therapy, occupational therapy, and speech therapy evaluate and treat as ordered. Observation on 02/17/26 at 12:30 P.M revealed Resident #34 with clear liquids on bedside table. Observation on 02/17/26 at 4:18 PM revealed Resident #34 with clear liquids on bedside table. Interview on 02/17/26 at 4:20 P.M. with LPN#104 confirmed Resident #34 has been getting clear liquids stating Resident #34 had an appointment the day prior and had an order for clear liquids. LPN #104 confirmed there was no order in Resident #34's medical record for clear liquid diet and was observed entering the clear liquid diet order into electronic medical record (EMR). Review of Resident #34's order/change of diet communication sheet for dietary staff revealed Resident #34 was upgraded to clear liquid diet on 02/16/26 with communication signed by LPN #104. Interview on 02/18/26 at 11:25 AM with Rehab Director confirmed Resident #34 did have swallow study and they advised she could tolerate clear liquid diet. The nurses are responsible for entering new diet orders when a resident comes from an appointment. Interview on 02/19/26 at 3:25 P.M. with Rehab Director and Regional Nurse revealed Resident #34's clear liquid diet order was not immediately entered because the facility's speech therapist was trying to clarify if Resident #34 should be on full liquid diet or clear liquid diet. Rehab Director and Regional Nurse confirmed the clear liquid diet order was communicated to the kitchen before clarification was received and Resident #34 was receiving clear liquid diet. 2. Review of the medical record revealed Resident #37 was admitted on [DATE] with diagnoses that included fracture of sacrum, major depressive disorder, and adjustment disorder with anxiety. Fall risk assessments dated 12/05/25, 12/27/25, 01/08/26, and 01/22/26 revealed Resident #37 was at high risk for falls. A care plan dated 12/08/25 revealed Resident #37 was at high risk for falls. Interventions included to encourage resident to use adaptive devices, ensure non-skid footwear, call light within reach, and bed in the lowest position. The 5-day Medicare Minimum Data Set (MDS) dated [DATE] revealed Resident #37 had cognitive impairment. A general progress note dated 12/27/25 at 1:14 A.M. revealed a Certified Nursing Assistant (CNA) went to answer Resident #37's call light and found the resident on his knees facing the bed. Resident #37 stated he slid off the bed. Resident #37 denied any pain or discomfort. A Fall Scene Investigation Report dated 12/27/25 revealed Resident #37 slipped, call light was functioning and bed height was not appropriate. The section for previous fall interventions in place was marked no. A general progress note dated 12/31/25 at 11:20 A.M. revealed the intradisciplinary team discussed Resident #37's fall. A new intervention was put in place for a mat to the floor on the right side of the bed. Resident stated he slid out of bed was found on knees on floor next to bed. No injuries noted. New intervention: Mat to floor exiting side of bed. MD DON and POA notified. A general progress note dated 01/08/26 at 4:01 A.M. revealed staff heard Resident #37 yelling for help. Resident #37 was found on the floor on the left side of the bed. Resident #37 stated he was trying to get out of bed. A Fall Scene Investigation Report dated 01/08/26 revealed Resident #37's call light was in reach and functional. No injuries were apparent. An interview on 02/19/26 at 2:26 P.M. Director of Nursing (DON) verified that the fall investigations for 12/27/25 and 01/08/26 were completed on paper forms and kept in the DON's office and not with the medical record. The DON stated information was also completed on risk management forms that were also not part of the medical record. DON verified that both fall investigations did not reveal if Resident #37 was wearing non-skid footwear and if the bed was in a low position. The Falls-Clinical protocol policy revised September 2012 revealed the staff will evaluate and document falls that occur while the individual is in the facility.

Based on observation, interview, record review, and policy review, the facility failed to ensure infection control procedures were followed during a dressing change for Resident #4. This affected one (Resident #4) out of two residents with percutaneous endoscopic gastrostomy (PEG) tubes. The facility census was 38. Findings include: Review of the medical record revealed Resident #4 was admitted on [DATE] with diagnoses that included Parkinson's disease, dementia associated with Parkinson's disease, muscle weakness, contractures, dysphagia, and recurrent urinary tract infections. A physician order dated 04/01/22 revealed Resident #4's peg tube site was to be cleansed with wound wash, patted dry, and a split gauze placed every shift. A plan of care dated 11/04/25 revealed Resident #4 required tube feeding due to dysphagia, swallowing problems, and malnutrition. Interventions included enhanced barrier precautions, and the head of the bed to be elevated greater than 30 degrees during and after tube feeding. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #4 had a Brief Interview Mental Status (BIMS) of 12 which indicated cognitive impairment. An observation on 02/18/26 at 11:48 A.M. revealed Licensed Practical Nurse (LPN) #311 washed her hands, applied gloves, and removed the split gauze pad around Resident #4's peg tube site. A small amount of reddish/brown drainage was noted on the gauze pad. LPN #311 did not remove her gloves or complete any type of hand hygiene. LPN #311 used a bottle of wound cleanser to clean the skin at the wound cite. LPN #311 then placed the bottle of wound cleanser on the bed next to Resident #4. LPN #311 placed a clean split gauze pad around the peg tube insertion cite. LPN #311 put the bottle of wound cleanser on Resident #4's over-the-bed table and then removed her gloves. LPN #311 then took the bottle of wound cleanser and placed it back in the treatment cart. An interview on 02/18/26 at 11:52 A.M. LPN #311 verified she did not remove her gloves after removing the soiled dressing. LPN #311 also verified that she placed the wound cleanser in Resident #4's bed and put the wound cleanser bottle back in the treatment cart before cleaning the bottle. Review of the Dressings, Dry/Clean policy revised September 2013 revealed hands should be washed and dried thoroughly, the soiled dressing removed, and to pull glove over dressing and discard into plastic or biohazard bag. Wash and dry hand thoroughly.

Based on record review, interview, and policy review, the facility failed to follow the antibiotic stewardship guidelines. Resident #37 was ordered antibiotics prior to the culture and sensitivity results being obtained. This affected one (Resident #37) out of six residents reviewed for unnecessary medications. The facility census was 38. Findings include: Review of the medical record revealed Resident #37 was admitted on [DATE] with diagnoses that included fracture of sacrum, major depressive disorder, adjustment disorder with anxiety, obstructive and reflux uropathy, and benign prostatic hyperplasia without urinary tract symptoms. Review of the December infection control log revealed Resident #37 had a urinary tract infection with an onset date of 12/31/25. Resident #37 was ordered Macrobid (antibiotic) and infection was resolved on 01/02/26. The January infection control log revealed Resident #37 had a urinary tract infection with an onset date of 12/31/25. Resident #37 was ordered Levofloxacin (antibiotic), and the infection was resolved on 01/09/26. A general progress note dated 12/31/25 revealed Resident #37's urinalysis was reviewed, and the resident was ordered Macrobid 100 milligrams (mg) twice a day until results of the culture were received. The medication administration record (MAR) revealed Resident #37 received Macrobid 100 mg the evening of 12/31/25 through the morning of 01/02/26.A general progress note dated 01/02/26 at 4:09 P.M. revealed a call was placed to the hospital requesting final culture and sensitivity results for Resident #37. The results were obtained, the nurse practitioner was notified, and new orders were received. Resident #37's Macrobid was to be stopped, and an order was received to start Levofloxacin 750 mg once a day for five days. Culture and sensitivity results dated 01/02/26 revealed the infection was resistant to Macrobid. A new order was received for Levofloxacin 750 mg daily for five days. The MAR revealed Resident #37 received Levofloxacin from 01/03/26 through 01/07/26. A plan of care dated 01/21/26 revealed Resident #37 was at risk for urinary retention. Interventions included to monitor for signs/symptoms of urinary tract infection. The 5-day Medicare Minimum Data Set (MDS) dated [DATE] revealed Resident #37 had a brief interview for mental status (BIMS) score of nine which indicated cognitive impairment. The MDS also revealed the resident had an indwelling catheter. An interview on 02/19/26 at 11:58 A.M. Director of Nursing (DON) verified Resident #37 was started on Macrobid before the culture and sensitivity came back. DON verified the infection was resistive to Macrobid and Resident #37 had to be started on another antibiotic. Antibiotic Stewardship-Orders for Antibiotics revised December 2016 revealed appropriate indications for use of antibiotics include pathogen susceptibility, based on culture and sensitivity.

Based on record review, review of the facility arbitration agreement, and staff interview, the facility failed to ensure their arbitration agreement had the required information that the signing resident or resident representative may communicate with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care Ombudsman as well as the agreement stated that the if the resident or resident representative would wish to cancel the arbitration agreement in within thirty (30) days, it does not have to be in writing. This affected 37 of 38 residents who signed the arbitration agreement. Resident #3 did not sign the arbitration agreement upon admission. The facility census was 38. Findings include: Review of the facility's admission packet revealed an arbitration agreement was within the admission packet. Review of resident medical records during the survey revealed arbitration agreements were signed by residents with the exception of the agreement for Resident #3, which was not signed upon admission. Review of the facility's arbitration agreement revealed the agreement did not state that the resident or resident representative may communicate with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care Ombudsman. The facility's arbitration agreement did not state the resident or resident representative has the right to cancel the arbitration agreement within thirty (30) days by providing written notice. Interview on 11/21/24 at 4:05 P.M. with the Administrator verified the facility's arbitration agreement that the residents sign upon admission did not include the resident or resident representative may communicate with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care Ombudsman and did not state the resident or resident representative has the right to cancel the arbitration agreement within thirty (30) days by providing written notice. The facility did not have a policy for arbitration agreements.

Based on staff interview, record review, and review of facility arbitration agreement, the facility failed to provide a neutral and fair arbitration process by ensuring both the resident or his or her representative, and the facility agree on the selection of a neutral arbitrator, and that the venue is convenient to both parties. This affected 37 of 38 residents who signed the arbitration agreement. Resident #3 did not sign the arbitration agreement upon admission. The facility census was 38. Findings include: Review of the facility's admission packet revealed an arbitration agreement was within the admission packet. Review of resident medical records during the survey revealed arbitration agreements were signed by residents with the exception of the agreement for Resident #3, which was not signed upon admission. Review of the facility's arbitration agreement revealed that by signing this Agreement, the Parties agree that, except as otherwise set forth herein, any action, claim, dispute or controversy of any kind, whether in contract, tort, statutory, common law, legal, equitable, or otherwise, during the term of the admissions agreement or hereafter arising between the parties in any way arising out of, pertaining to, or in connection with, the provision of health care services or any agreement between the parties including, but not limited to, the scope of this agreement with, and the arbitrability of, any claim or dispute, against whomever made (including, to the full extent permitted by applicable laws, third parties who are not signatories to this Agreement) shall be resolved by binding arbitration administered by the American Arbitrators Association (AAA). If the AAA does not enforce pre-dispute arbitration agreements, then any other reasonably comparable arbitration association chosen solely by the facility shall be an acceptable replacement. The agreement does not allow the resident or resident representative to seek other counsel except American Arbitrators Association (AAA) for binding arbitration disputes. This did not ensure both the resident or his or her representative, and the facility agree on the selection of a neutral arbitrator The facility's arbitration agreement revealed that in the event a court having jurisdiction finds any portion of the arbitration agreement or the admissions agreement unenforceable, that portion shall not be effective, and the remainder of the agreements shall remain effective. If a court finds that all of the provisions in this agreement providing for binding arbitration are unenforceable, then such provisions shall be replaced with a waiver of jury trial in accordance with the laws of Ohio without regards to its conflicts of law, and the venue shall be in the closest proper venue to the facility's principal place of business. This does not allow for the resident or resident representative to agree with the venue. An interview on 11/21/24 at 4:05 P.M. with the Administrator verified the facility's arbitration agreement did not provide a neutral and fair arbitration process by ensuring both the resident or his or her representative, and the facility agree on the selection of a neutral arbitrator, and that the venue is convenient to both parties. The facility did not have a policy for arbitration agreements.

Based on review of the facility assessment, personnel record review, and staff interview, the facility failed to provide behavioral health education to all staff in orientation and annually thereafter. This had the potential to affect all 38 residents residing in the facility. Findings include: Review of the facility assessment dated [DATE] revealed the facility accepted residents with psychiatric disorders to include impaired cognition, mental disorder, bipolar, schizophrenia, post-traumatic stress disorder, anxiety disorder, and behaviors which required interventions. Review of the personnel file for Dietary Aide #500 revealed a hire date of 07/24/24 and no evidence the employee received training on mental health behaviors. Review of the personnel file for Housekeeper #209 revealed a hire date of 09/16/24 and no evidence the employee received training on mental health behaviors. Review of the personnel file for License Practical Nurse (LPN) #213 revealed a hire date of 07/24/24 and no evidence the employee received training on mental health behaviors. Review of the personnel file for Certified Nursing Assistant (CNA) #223 revealed a hire date of 08/21/20 and no evidence the employee received training on mental health behaviors. Review of the personnel file for CNA #203 revealed a hire date of 06/01/22 and no evidence the employee received training on mental health behaviors. Review of the personnel file for CNA #227 revealed a hire date of 11/08/21 and no evidence the employee received training on mental health behaviors. Review of the annual in-service for facility staff revealed that the in-service for behavior training was scheduled in December 2024. An interview with the Administrator on 11/21/24 at 9:30 A.M. revealed there was an annual in-service scheduled for behavioral training in December 2024. The Administrator stated she could not find any documentation that behavior training was provided to all staff at orientation or completed in the previous twelve months. The Administrator also verified the facility assessment included the facility accepted residents with psychiatric disorders to include impaired cognition, mental disorder, bipolar, schizophrenia, post-traumatic stress disorder, anxiety disorder, and behaviors which required interventions.

Based on observation, staff interview, test tray, and record review, the facility failed to serve pureed foods at a smooth consistency for residents on a mechanically altered diet. This had the potential to affect four residents (#4, #5, #23, and #30) identified by the facility who were prescribed pureed diets. The facility census was 38. Findings include: The observation of puree preparation on 11/18/24 at 10:50 A.M. revealed Dietary Manager (DM) #200 changed the puree vegetable for lunch to pureed peas. She stated the squash in the mixed vegetables sometimes does not puree correctly to a smooth consistency because of the rind. [NAME] #241 pureed the peas for several minutes and was tasting the peas as she was going. She took the pureed peas out of the robot coupe container, put the pureed peas into bowls for the residents, portioned a small amount into a five-ounce dessert dish with a plastic spoon. The taste test on 11/18/24 at 10:50 A.M. revealed the pureed peas were not of a smooth consistency and had pieces of the pea shells in it. The Regional Director of Culinary (RDC) #251 tasted the purees and verified the peas needed to be pureed more. RDC #251 recommended DM #200 to puree the menu item. [NAME] #241 pureed the mixed vegetables to the correct consistency for lunch service. The facility identified four residents, Residents #4, #5, #23, and #30, who were prescribed pureed diets Review of the undated facility's policy titled Pureed Food Preparation revealed the foods would be pureed to assure desire consistency.

Based on observation, record review, and resident and staff interview, the facility failed to ensure Resident #141 was aware of the location and how to use the bathroom call light. This affected one (#141) of 19 residents reviewed in the initial sample of the annual survey. The facility census was 38. Findings include: Record review revealed Resident #141 was admitted to the facility on [DATE] with diagnoses including necrotizing fasciitis, Fournier gangrene, and diabetes mellitus. The admission Minimum Data Set (MDS) 3.0 assessment was in progress. Review of the care plan dated 11/12/24 revealed Resident #141 had a potential risk for falls related to weakness from hospital stay for necrotizing fasciitis labia majora and groin with Fournier gangrene with surgical debridement. Interventions included but not limited to call light within reach. An interview on 11/18/24 at 9:40 A.M. with Resident #141 revealed she felt unsafe in the bathroom because there was no call light in it. Observation and interview on 11/18/24 at 9:40 A.M. revealed there was no indication that a call light was available to Resident #141 in the bathroom. An interview with Maintenance Director (MD) #207 at the time of the observation stated there was a light switch next to the toilet tissue that was the call light but there was no red cord or label to indicate that it was a call light.

Based on resident, staff, and physician interview, record review, policy review, and Standard of Care by the American Diabetic Association, the facility failed to ensure Resident #39's representative was timely notified following a change in condition and failed to ensure Resident #21's physician was notified timely following a new diagnosis of diabetes mellitus. This affected two (Residents #21 and #39) of two residents reviewed for change of condition. The facility census was 38. Findings include: 1. Record review for Resident #39 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included chromic obstructive pulmonary disease, chronic kidney disease, psychoactive substance abuse, and paranoid schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact and was independent for activities of daily living. Review of the progress note for Resident #39 dated 08/30/24 at 9:36 A.M. revealed Resident #39 was sitting on the side of her bed at 6:00 A.M. when the nurse came on duty this am. A short time later while passing medications, the front door alarm went off. Resident #39 was ambulating with wheeled walker on front porch. A woman friend in a blue four-door car was waiting for her. The nurse asked what she was doing. Resident #39 yelled, I am leaving, and I am not coming back. The nurse asked her what was wrong, and she replied that you do not want to know. Resident #39 was educated on consequences of leaving against medical advice (AMA). Resident #39 yelled to the nurse, I don't give a [expletive], and got in the vehicle. The nurse explained to the visitor that Resident #39 was not to leave the facility unsupervised. The visitor shook her head and drove away with Resident #39 in front seat of the vehicle. There was no documentation the emergency contact was notified of Resident #39 leaving AMA. An interview on 11/19/24 at 12:03 P.M. with Social Service Designee (SSD) #234 stated she was not at the facility the day that Resident #39 left AMA. She heard at the morning meeting that she had left. Resident #39 contacted her about getting her items that were left in the room. SSD #234 stated that different agencies put Resident #39 in hotels. SSD #234 verified the emergency contact was not called after Resident #39 went AMA in the electronic chart. Interview on 11/19/24 at 12:23 P.M. with the Administrator stated the daughter was called but there was no documentation that shows she was called. The Administrator stated the resident was her own person but left AMA. Review of the facility policy titled Change in Resident's Condition or Status revised December 2016 revealed the facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and or status. 34298 2. Review of the medical record revealed Resident #21 was admitted on [DATE] and readmitted on [DATE] with diagnoses including post traumatic seizures, encephalopathy, traumatic brain injury, type II diabetes mellitus (DM), and acute respiratory failure. Review of the hospital notes dated 05/27/24 revealed Resident #21 had a history of traumatic brain injury in January 2022, intracerebral hemorrhage, seizure disorder, mood disorder, DM, and encephalopathy. The summary of hospitalization did not reveal diagnosis of DM or use of glycemic medication. A care plan dated 06/05/24 revealed Resident #21 had DM type II. Interventions included accuchecks as ordered, administer medications as ordered, labs as ordered, monitor blood sugar levels as ordered by physician. Abnormal blood glucose levels were to be covered per sliding scale as ordered by physician, and to monitor for hyperglycemia/hypoglycemia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively intact. The MDS assessment revealed Resident #21 did not receive any insulin injections or hypoglycemic medications. Review of the medication administration record (MAR) and physician orders from 06/05/24 through 10/29/24 revealed no blood glucose monitoring or antidiabetic medications or an A1C (blood test to measure the average blood glucose levels over the past three months). A progress note dated 10/29/24 at 10:47 A.M. revealed Resident #21 was sent to the hospital for evaluation due to history of seizures. Resident #21 appeared unsteady and short of breath. Emergency Department (ED) visit summary dated 10/29/24 revealed Resident #21 had blood glucose in the mid 500s with sodium of 124 milliequivalent's per liter (mEq/L). The low sodium level was likely from pseudohyponatremia from hyperglycemia. Resident #21 was given a dose of insulin in the ED. A recommendation for hospitalization was made but Resident #21 wanted to go back to the nursing home. It was discussed extensively with the nursing home a type II DM diagnosis on Resident #21's medical history, but the MAR did not show Resident #21 received any insulin. It was also discussed with the nursing home the importance of giving Resident #21 insulin. Review of the blood glucose monitoring on 10/30/24 at 1:01 P.M. revealed Resident #21's blood glucose level was 586 milligrams per deciliter (md/dL). On 10/30/24 at 4:32 P.M., Resident #21's blood glucose was 387 mg/dL, and at 9:31 P.M., it was 513 mg/dL. Physician orders dated 10/30/24 revealed Resident #21 was ordered Humalog (insulin) per sliding scale, Metformin (antidiabetic), and Lantus 10 units. Resident #21 was ordered a continuous glucose monitoring sensor. Resident #21's blood glucose levels from 10/31/24 to 11/19/24 ranged from 153 mg/dL (on 11/10/24) to 536 mg/dL. Interview on 11/18/24 at 9:39 A.M. with Resident #21 stated he was given the wrong medication or it was not administered correctly and he had to go to the hospital. Resident #21 stated his blood glucose was 500 at the hospital. Interview on 11/19/24 at 11:59 A.M. with the Director of Nursing (DON) stated the diagnosis of type II DM for Resident #21 was added on 06/05/24. The DON stated Resident #21 returned to the facility from the hospital and the MDS nurse found in the diagnosis in the paperwork and added it the Resident #21's current diagnoses. The DON verified there was no monitoring of Resident #21's blood glucose levels or anti-diabetic medications ordered until 10/30/24. Interview on 11/20/24 at 8:15 A.M. with MDS Nurse #300 verified the diagnoses and care plan for type II DM was added when Resident #21 returned from the hospital in June. MDS Nurse #300 verified the doctor should be notified of any new diagnosis and the care plan had interventions that were not put in place. Interview on 11/20/24 at 12:32 P.M. with Medical Director (MD) #253 stated he was not aware a diagnosis of type II DM had been added in June for Resident #21. MD #253 stated the discharge summary and medication list of the hospital in June did not list any diagnosis or medication for DM and MD #253 did not look through all the paperwork sent from the hospital. MD #253 stated an A1C would have been ordered if MD #253 had been aware of a diagnosis of type II DM being added for Resident #21. MD #253 stated additional orders for blood glucose monitoring and medications would have been ordered depending on the results of the A1C. Review of the policy and procedure of Nursing Care of the Resident with DM revised December 2015 revealed the purpose of the guideline is to help the resident control his/her diabetes with diet, exercise and insulin (as ordered), prevent recurrent hyperglycemia/hypoglycemia, recognize, manage, and document the treatment of complications commonly associated with DM. The management of individuals with DM should follow relevant protocols and guidelines. The physician will order the frequency of glucose monitoring. Finger sticks (capillary blood sample) measure current blood glucose levels. The normal ranges are defined as 80-130 mg/dL before meals and less than 180 mg/dL after meals. Hyperglycemia is considered anything above the target reference ranges. Medication management of type II DM may include oral hypoglycemic agents with or without insulin. According to the Older Adults: Standard of Care in Diabetes-2024 by the American Diabetes Association dated January 2024 Treatment in skilled nursing facilities and nursing homes revealed management of diabetes in the long-term care (LTC) setting is unique. Individualization of health care is important for all people with diabetes; however, practical guidance is needed for health care professionals as well as the LTC staff and caregivers. Training should include diabetes detection and institutional quality assessment. LTC facilities should develop their own policies and procedures for prevention, recognition, and management of hypoglycemia.

Based on record review and interview the facility failed to ensure documentation was completed and physician notification occurred prior to a hospitalization for Resident #29. This affected one (#29) of two residents reviewed for hospitalization . The facility census was 38. Findings include: Record review for Resident #29 revealed an admitted [DATE]. diagnosed included diabetes mellitus, chronic kidney disease, and malignant neoplasm of duodenum. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was cognitively intact and required set up assistance for activities of daily living. Review of the progress note for Resident #29 dated 11/17/24 at 12:10 P.M. revealed Resident #29 requested to go to emergency room (ER) due to stomach being bloated. There were no signs and symptoms of clostridioides difficile (C-diff). Resident on Augmentin (antibiotic) for urinary tract infection (UTI). The husband was at bedside. Emergency services (911) called with report. Review of the progress note for Resident #29 dated 11/17/24 at 5:35 P.M. revealed Resident #29 returned from hospital at 5:00 P.M. by stretcher and two emergency medical technicians. No masses, bowel obstructions, or C-diff noted. Fluid and Zofran were given at the hospital. Resident #29 was alert and oriented. Review of Resident #29's medical record revealed no documentation that Resident #29 was assessed prior to going to the hospital. Interview on 11/21/24 at 10:47 A.M. with [NAME] President of Operations (VPO) # 250 verified that hospital transfer papers for Resident #29 were not in the medical chart to show the reason the resident was transferred and that the doctor was notified. Review of the facility policy titled Change in Resident's Condition or Status revised December 2016 revealed that prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider.

Based on record review, resident, staff, and physician interview, review of the Older Adults: Standard of Care in Diabetes-2024 by the American Diabetes Association, and policy and procedure for Nursing Care of the Resident with Diabetes Mellitus, the facility failed to provide diabetic care in accordance with professional standards after a diagnosis of type II diabetes mellitus was added to Resident #21's diagnoses. This affected one (#21) of 18 residents reviewed for standards of care. The facility census was 38. Findings include: Review of the medical record revealed Resident #21 was admitted on [DATE] and readmitted on [DATE] with diagnoses including traumatic brain injury, type II diabetes mellitus (DM), and acute respiratory failure. Review of the hospital notes dated 05/27/24 revealed Resident #21 had a history of traumatic brain injury in January 2022, intracerebral hemorrhage, seizure disorder, mood disorder, DM, and encephalopathy. The summary of hospitalization did not reveal diagnosis of DM or use of glycemic medication. A care plan dated 06/05/24 revealed Resident #21 had DM type II. Interventions included accuchecks as ordered, administer medications as ordered, labs as ordered, monitor blood sugar levels as ordered by physician. Abnormal blood glucose levels were to be covered per sliding scale as ordered by physician, and to monitor for hyperglycemia/hypoglycemia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively intact. The MDS assessment revealed Resident #21 did not receive any insulin injections or hypoglycemic medications. Review of the medication administration record (MAR) and physician orders from 06/05/24 through 10/29/24 revealed no blood glucose monitoring or antidiabetic medications or an A1C (blood test to measure the average blood glucose levels over the past three months). A progress note dated 10/29/24 at 10:47 A.M. revealed Resident #21 was sent to the hospital for evaluation due to history of seizures. Resident #21 appeared unsteady and short of breath. Emergency Department (ED) visit summary dated 10/29/24 revealed Resident #21 had blood glucose in the mid 500s with sodium of 124 milliequivalent's per liter (mEq/L). The low sodium level was likely from pseudohyponatremia from hyperglycemia. Resident #21 was given a dose of insulin in the ED. A recommendation for hospitalization was made but Resident #21 wanted to go back to the nursing home. It was discussed extensively with the nursing home a type II DM diagnosis on Resident #21's medical history, but the MAR did not show Resident #21 received any insulin. It was also discussed with the nursing home the importance of giving Resident #21 insulin. Review of the blood glucose monitoring on 10/30/24 at 1:01 P.M. revealed Resident #21's blood glucose level was 586 milligrams per deciliter (md/dL). On 10/30/24 at 4:32 P.M., Resident #21's blood glucose was 387 mg/dL, and at 9:31 P.M., it was 513 mg/dL. Physician orders dated 10/30/24 revealed Resident #21 was ordered Humalog (insulin) per sliding scale, Metformin (antidiabetic), and Lantus 10 units. Resident #21 was ordered a continuous glucose monitoring sensor. Resident #21's blood glucose levels from 10/31/24 to 11/19/24 ranged from 153 mg/dL (on 11/10/24) to 536 mg/dL. Interview on 11/18/24 at 9:39 A.M. with Resident #21 stated he was given the wrong medication or it was not administered correctly and he had to go to the hospital. Resident #21 stated his blood glucose was 500 at the hospital. Interview on 11/19/24 at 11:59 A.M. with the Director of Nursing (DON) stated the diagnosis of type II DM for Resident #21 was added on 06/05/24. The DON stated Resident #21 returned to the facility from the hospital and the MDS nurse found in the diagnosis in the paperwork and added it the Resident #21's current diagnoses. The DON verified there was no monitoring of Resident #21's blood glucose levels or anti-diabetic medications ordered until 10/30/24. Interview on 11/20/24 at 8:15 A.M. with MDS Nurse #300 verified the diagnoses and care plan for type II DM was added when Resident #21 returned from the hospital in June. MDS Nurse #300 verified the doctor should be notified of any new diagnosis and the care plan had interventions that were not put in place. Interview on 11/20/24 at 12:32 P.M. with Medical Director (MD) #253 stated he was not aware a diagnosis of type II DM had been added in June for Resident #21. MD #253 stated the discharge summary and medication list of the hospital in June did not list any diagnosis or medication for DM and MD #253 did not look through all the paperwork sent from the hospital. MD #253 stated an A1C would have been ordered if MD #253 had been aware of a diagnosis of type II DM being added for Resident #21. MD #253 stated additional orders for blood glucose monitoring and medications would have been ordered depending on the results of the A1C. Review of the policy and procedure of Nursing Care of the Resident with DM revised December 2015 revealed the purpose of the guideline is to help the resident control his/her diabetes with diet, exercise and insulin (as ordered), prevent recurrent hyperglycemia/hypoglycemia, recognize, manage, and document the treatment of complications commonly associated with DM. The management of individuals with DM should follow relevant protocols and guidelines. The physician will order the frequency of glucose monitoring. Finger sticks (capillary blood sample) measure current blood glucose levels. The normal ranges are defined as 80-130 mg/dL before meals and less than 180 mg/dL after meals. Hyperglycemia is considered anything above the target reference ranges. Medication management of type II DM may include oral hypoglycemic agents with or without insulin. According to the Older Adults: Standard of Care in Diabetes-2024 by the American Diabetes Association dated January 2024 Treatment in skilled nursing facilities and nursing homes revealed management of diabetes in the long-term care (LTC) setting is unique. Individualization of health care is important for all people with diabetes; however, practical guidance is needed for health care professionals as well as the LTC staff and caregivers. Training should include diabetes detection and institutional quality assessment. LTC facilities should develop their own policies and procedures for prevention, recognition, and management of hypoglycemia.

Based on record review, policy review, and staff interview, the facility failed to identify if the pharmacy had any irregularities or recommendations from June 2024 through October 2024. This affected three (Resident #10, #29, and #33) of five residents reviewed for unnecessary medications. The facility census was 38. Findings include: 1. Review of the medical record revealed Resident #10 was admitted on [DATE] with diagnoses that included Fourier gangrene, paralytic, neuromuscular dysfunction, colostomy, bipolar disorder, convulsions, anxiety disorder, and major depressive disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact. Resident #10 received antianxiety, antidepressant, anticoagulant, and opioid medications. The physician orders included Effexor (antidepressant), Percocet (opioid pain medication) hydroxyzine (to treat anxiety), Keppra (anticonvulsant), apixaban (anticoagulant), amantadine (antidyskinetic), and paliperidone (antipsychotic) Review of the monthly pharmacy reviews revealed Resident #10's medications were reviewed in June 2024, July 2024, September 2024, and October 2024. (Resident #10 was at the hospital at the time of the August 2024 pharmacy review). The pharmacy reviews did not indicate if there were any irregularities or recommendations for Resident #10 when the monthly reviews were done. Interview on 11/21/24 at 1:57 P.M. with [NAME] President of Clinical Services #254 verified the monthly pharmacy reviews did not indicate if there were any irregularities or recommendations for Resident #10 during the months of June 2024, July 2024, September 2024, and October 2024. The facility contacted the pharmacy representative. The pharmacy representative stated they just sent individual recommendation via email to the Director of Nursing (DON) but did not provide a list of residents that had recommendations each month. [NAME] President of Clinical Services #254 verified there was nothing to ensure all the recommendations were received and addressed by the physician. 2. Review of the medical record revealed Resident #33 was readmitted on [DATE] with diagnoses including congestive heart failure, morbid obesity, hypoxemia, pain, presbyopia, macular degeneration, anxiety, depressive disorder, dysphagia, neuropathy, duodenal ulcer, hypertension, chronic kidney disease, and hyperlipidemia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively intact. Resident #33 received antianxiety, antidepressant, diuretic, opioid, and antiplatelet medications. The physician orders included Tramadol (opioid pain medication) Lexapro (treats anxiety and depression), Prazosin (to treat post-traumatic stress disorder), Buspar (antianxiety), Lasix (diuretic), hydrozyzine (treats anxiety), and Bupropion (antidepressant). Review of the monthly pharmacy reviews revealed Resident #33's medications were reviewed in June 2024, July 2024, August 2024, September 2024, and October 2024. The pharmacy reviews did not indicate if there were any irregularities or recommendations for Resident #33 when the monthly reviews were done. Interview on 11/21/24 at 1:57 P.M. with [NAME] President of Clinical Services #254 verified the monthly pharmacy reviews did not idicate if there were any irregularities or recommendations for Resident #33 during the months of June 2024, July 2024, August 2024, September 2024, and October 2024. The facility contacted the pharmacy representative. The pharmacy representative stated they just sent individual recommendation via email to the Director of Nursing (DON) but did not provide a list of residents that had recommendations each month. [NAME] President of Clinical Services #254 verified there was nothing to ensure all the recommendations were received and addressed by the physician. 39333 3. Record review for Resident #29 revealed an admitted [DATE]. Diagnoses included diabetes mellitus, chronic kidney disease, and malignant neoplasm of duodenum. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was cognitively intact and required set up for activities of daily living. Resident #29 received antipsychotics, antidepressants, diuretics, antiplatelets, and opioids during the seven-day look back period. Review of the current physician's orders revealed Resident #29 was ordered bupropion (antidepressant), lurasidone (antipsychotic), Oxycodone with acetaminophen (opioid pain medication) and Lasix (diuretic). Review of the monthly pharmacy reviews revealed Resident #29's medications were reviewed in June 2024, July 2024, August 2024, September 2024, and October 2024. The pharmacy reviews did not indicate if there were any irregularities or recommendations for Resident #29 when the monthly reviews were done. Interview on 11/21/24 at 1:57 P.M. with [NAME] President of Clinical Services #254 verified the monthly pharmacy reviews did not indicate if there were any irregularities or recommendations for Resident #29 during the months of June 2024, July 2024, August 2024, September 2024, and October 2024. The facility contacted the pharmacy representative. The pharmacy representative stated they just sent individual recommendation via email to the Director of Nursing (DON) but did not provide a list of residents that had recommendations each month. [NAME] President of Clinical Services #254 verified there was nothing to ensure all the recommendations were received and addressed by the physician. Review of the facility's Medication Regimen Reviews policy and procedure revised April 2007 revealed the primary purpose of the review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible. The Consultant Pharmacist will document his/her findings and recommendations on the monthly drug/medication regimen review report. The Consultant Pharmacist will provide a written report to physicians for each resident with an identified irregularity. The Consultant Pharmacist will provide the DON and Medical Director with a written, signed and dated copy of the report, listing the irregularities found and recommendations for their solutions.

Based on observations, resident council meeting minutes, review of past survey history and staff interviews, the facility failed to ensure the bottom half of the walls throughout the facility were in good repair. This could potentially affect all 40 residents residing in the facility at the time of the investigation. Findings include: Observation of the facility occurred on 07/07/23 at 6:48 A.M., which consists of one long hallway. The lower half of the hallway was observed to have sheetrock with many missing sections, gouges and is unpainted, throughout the facility. Review of the annual Life Safety code (LSC) inspection dated 11/09/22 revealed the facility received a deficiency related to the carpet on the lower half of the walls throughout the facility. The documented plan of correction indicated the facility removed all the carpet on the walls on 11/30/22. Review of the resident council meeting minutes identified in April, May and June 2023 the residents questioned when the walls would be fixed. Interview with the facility Administrator occurred on 07/07/23 at 7:16 A.M. and confirmed the walls have not been repaired and the facility has been working on getting approval. This deficiency represents non-compliance investigated under Complaint Number OH00143288.

Based on record review and staff interview, the facility failed to ensure Quality Assessment and Assurance (QAA) committee meetings were conducted quarterly. This had the potential to affect all 42 residents in the facility. Findings Include: Review of the facility QAA committee meeting minutes revealed the most recent QAA Committee meetings were 01/26/22 and 02/23/22. There were no further quarterly meetings completed for 2022. Interview on 11/09/22 at 1:02 P.M. with Administrator confirmed the last QAA committee meeting was January and February of 2022 and they had not had a meeting since.

Based on medical record review, and physician, pharmacy and staff interviews, the facility failed to adequately monitor blood coagulation levels of one resident (Resident #105) who received anticoagulants and antibiotics. This resulted in Actual Harm for Resident #105 who required hospital treatment, five units of blood and intravenous vitamin K. This affected one of six residents identified as receiving a blood thinning agent. Findings include: Review of Resident #105's medical record identified admission to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Resident #105 was started on a blood thinning medication ([MEDICATION NAME]) in the hospital just prior to admission. Review of Resident #105's record identified the facility checked [MEDICATION NAME]/international normalized ratio (PT/INR), test to measure clotting factors and time it takes for blood to clot, levels on a facility machine. The facility's PT/INR machine had identified normal ranges for PT of 6.5-11.9, and for INR of 0.7-1.2 (with 2.0-3.0 ideal for treatment). Resident #105's results were on 06/19/14 PT 48.4/INR 4.8; on 06/23/14 PT 58.4/INR 5.8; on 06/24/14 PT 54.5/INR 5.5 ; and on 06/25/14 PT 48.6/INR 4.9. On 06/25/14 Resident #105 was sent to the hospital following elevated PT/INR results obtained in the facility. Hospital laboratory results on 06/25/14 at 7:42 P.M. were PT 56.5 (9.2-11.6) and INR 5.2 Critical High (0.8-1.1); with the plan to hold [MEDICATION NAME] and check PT/INR daily. Resident #105 returned to the facility on [DATE] with a physician's orders [REDACTED]. The hospital discharge [DIAGNOSES REDACTED]. Review of the record lacked evidence the facility obtained the INR results for 06/30/14. Interview with the Director of Nursing (DON) on 08/01/14 at 9:53 A.M. confirmed Resident #105 was ordered a daily INR when he returned from the hospital on [DATE] and there was no evidence this was completed on 06/30/14. On 07/01/14 Resident #105's primary physician visited the resident and ordered the antibiotics Bactrim and [MEDICATION NAME] and ordered PT/INR in one week. The pharmacy on 07/01/14 sent the facility a notification of "potential drug interaction" between the Bactrim and [MEDICATION NAME]. The notification "if both drugs are administered monitor [MEDICATION NAME] activity or INR value and observed for signs and symptoms of bleeding. The dosage of [MEDICATION NAME] ([MEDICATION NAME]) may need adjusted. The time of the highest interaction is when the precipitant drug is initiated or discontinued". The potential drug interaction was listed at Severity Level #2. The resident's record contained no evidence that the pharmacy's notice was addressed by the facility or given to the resident's physician. Review of the nurse notes dated 07/06/14 identified on 07/05/14 at 8:00 P.M. Resident #105 had shortness of breath with any movement, had a high heart rate and passed out when he was sitting on the bed side. Physician #150 was called and ordered Resident #105 sent to the hospital. Review of hospital records revealed Resident #105 arrived at the hospital on [DATE] and they assessed him to have increasing shortness of breath, and stool dark and tarry (indication of blood in stool). The hospital completed laboratory tests on 07/05/14 at 9:44 P.M. that included a critical hemoglobin of 6.1 (14-18 normal); platelets 55 (130-400); critical high INR of 11.3 (0.8-1.1) and high PT of 123.6 (9.2-11.6), and identified they were presumed high level due to antibiotic use and [MEDICATION NAME]. Resident #105 was admitted to the hospital intensive care unit and required three units of packed red blood cells and two units of fresh frozen plasma along with intravenous Vitamin K (used to help the blood clot). A phone interview with Pharmacist #200 on 07/31/14 at 11:55 A.M. revealed the severity levels range from 1-9 with 1 being the worst, and were based on a national register. The pharmacy identified very important issues with [MEDICATION NAME] and antibiotics used concurrently. The pharmacist revealed they called the facility to notify them of the potential interaction as the interaction really affected INR levels. The pharmacist confirmed the pharmacy called the facility on 07/01/14 at 4:36 P.M. and did not receive an answer so they also faxed over the interaction form. Interview revealed when the Bactrim and [MEDICATION NAME] were shipped to the facility in the medication tote, the manifest would list potential interactions and another notification of potential interaction would be in the tote. Interview of Unit Manager RN #60 on 07/31/14 at 9:29 A.M. revealed she stated, "The interaction forms come in the tote from the pharmacy and all the staff nurses give the forms to me. I then place the forms into the physician's folder and give them to him on Tuesdays when he comes in and they are not reviewed prior to Tuesday." Interview with Physician #150 on 07/31/14 at 12:34 P.M. revealed there was no communication from the facility as to what happened while Resident #105 was in the hospital. No discharge summary was ever provided to the physician from the hospital or the facility. He said if he would have gotten the information that was on the script from the hospital he would have left the INR daily. He would have written "change" on the physicians order if he would have known they ordered the INR daily in the hospital. The physician confirmed on 07/01/14 he was not notified by the facility of the pharmacy sending the potential reaction forms for Resident #105's [MEDICATION NAME] and Bactrim. This deficiency substantiates Complaint Number OH 648.

Based on medical record review, observation, and staff interview, the facility failed to provide care and treatment for [REDACTED]. This affected one of 14 sampled residents reviewed. Findings include: Medical record review revealed Resident #56 was admitted to facility on 07/18/11 with [DIAGNOSES REDACTED]. Review of the Admission Data Collection form (dated 07/18/11) revealed Resident #56's cognition was modified independent for daily decision making, non-weight bearing of the right foot, total assist with transfers, ace wrap and soft cast to right foot, and non-ambulatory. Review of the medical record revealed no documented evidence of a physician order, monitoring, treatment or care plan for Resident #56's right ankle soft cast. Review of daily record of therapy treatment note dated 07/18/11 revealed Resident #56 was to wear a soft cast for two to four weeks with an ace wrap. On 08/03/11 at 10:30 A.M., observation revealed Resident #56 was ambulating with therapy with a wheeled walker and an ace wrap to the right ankle. On 08/03/11 at 11:02 A.M., interview with Registered Nurse #12 verified the medical record revealed no documented evidence of a care plan, physician order [REDACTED]. On 08/03/11 at 11:07 A.M., interview with Therapist #18 verified nursing was to be monitoring the soft cast and ace wrap and the cast was to be worn at all times.