Every finding on record at Williams Co Hillside Country L

Based on observation, staff interview, review of the facility's water management program, review of the Centers for Disease Control (CDC) guidance and review of facility policy, the facility failed to meet the requirements for a Legionella water management program. This had the potential to affect all residents. Additionally, the facility failed to maintain infection control practices during insulin administration. This affected one resident (#18) for administration of insulin. The facility census was 65. Findings include: 1. Interview on 02/27/25 at 9:15 A.M. with Maintenance Director (MD) #486 revealed the facility had eye wash stations and a whirlpool. MD #486 verified the eye wash stations and whirlpool were not flushed to prevent the buildup of bacteria. A follow-up interview on 02/27/25 at 9:30 A.M. with MD #486 verified the facility did not have a risk assessment or flow chart/diagram describing the water systems and offered the blueprint of the building. MD #486 also verified chlorination levels were only tested on ce a week in the facility. Interview on 02/27/25 at 11:53 A.M. with the Administrator confirmed the facility did not meet the requirements for the legionella prevention water management system. Review of the Legionella Prevention Weekly Free Chlorine Log, dated 1/23/23 to 2/24/25, verified chlorination levels were only tested in one room once per week. Review of the Water Plan Operating Report, dated 01/01/24 to 01/31/25, revealed the plant tap/entry point chlorination levels were to be tested daily. Review of the facility policy titled, Legionella Environmental, dated 03/09/20, revealed chlorination levels were checked daily, both in the treatment plant and inside the facility, to ensure disinfection tolerances. In addition, chlorination levels at the furthest point of use were monitored on a weekly basis to ensure residual chlorination was adequate to prevent Legionella growth. Review of the undated CDC guidance titled, Overview of Water Management Programs, revealed water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program was a multi-step process that required continuous review. Further review revealed the seven key elements of a Legionella water management program were to: Establish a water management program team Describe the building water systems using text and flow diagrams Identify areas where Legionella could grow and spread Decide where to apply and how to monitor control measures Establish interventions when control limits were not met Ensure the program was running as designed and is effective Document and communicate all the activities 47057 2. Review of the medical record for Resident #18 revealed an admitted [DATE] with diagnoses of diabetes mellitus and long term use of insulin. Review of the annual Minimum Data Set (MDS) assessment, dated 11/17/24, revealed Resident #18 was cognitively intact. Review of the February 2025 physician orders for Resident #18 revealed she was prescribed Fiasp FlexTouch subcutaneous solution injector-pen (fast acting insulin) 100 unit/milliliter (ml), inject eight units three times a day. Observation on 02/24/25 at 12:02 P.M. of insulin administration for Resident #18 revealed Registered Nurse (RN) #511 administered the resident's insulin without donning a pair of gloves. Concurrent interview with RN #511 verified she did not don gloves to administering the injectable insulin to Resident #18. Review of the facility policy titled, Bloodborne Pathogen Exposure Control, revised July 2023, revealed the facility established a safety plan for all employees who handle, store, use, process, or dispose of potentially infected blood and blood products. Further review revealed to wear disposable latex or vinyl gloves if handling blood, blood products or body secretions.

Based on observation, staff interview, medical record review and review of facility policy, the facility failed to ensure non-pasteurized eggs were cooked appropriately. This affected three (#11, #23, and #40) residents who received soft cooked eggs from the kitchen. Additionally, the facility failed to ensure staff practiced proper hand hygiene while providing meal assistance. This affected two (#26 and #49) residents observed during meal service. The facility identified five additional residents (#10, #16, #29, #41, and #58) who required assistance during meals. The facility census was 65. Findings include: 1. Review of the medical record for Resident #11 revealed an admitted [DATE] with a diagnosis of hypertension. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/22/24, revealed Resident #11 had intact cognition and required set-up or clean-up assistance with meals. Further review of the physician order initiated 08/15/23 revealed Resident #11 received a regular diet. Review of the medical record for Resident #23 revealed an admitted [DATE] with a diagnosis of congestive heart failure. Review of the modified annual comprehensive MDS assessment, dated 11/26/24, revealed Resident #23 had intact cognition and required set-up or clean-up assistance with meals. Further review of the physician order initiated 11/23/23 revealed Resident #23 received a regular diet. Review of the medical record for Resident #40 revealed an admitted [DATE] with diagnoses of hypertension and chronic kidney disease. Review of the quarterly MDS assessment, dated 01/27/25, revealed Resident #40 had impaired cognition and required set-up or clean-up assistance with meals. Further review of the physician order initiated 05/13/22 revealed Resident #40 received a regular diet. Observation on 02/24/25 at 8:28 A.M. of the kitchen revealed an 18-count carton of eggs near the griddle. Further observation revealed the egg carton did not indicate the eggs were pasteurized. Concurrent interviews with [NAME] #446 and [NAME] #464 confirmed the facility ran out of pasteurized eggs and the eggs used for the morning meal were unpasteurized. Further interview with [NAME] #446 stated she prepared medium cooked eggs for Resident #11, and soft cooked eggs for Resident #23 and Resident #40. Review of the policy titled, Food Service - Serving Eggs to Residents, revised 05/25/21, revealed pasteurized eggs would be used to prepare soft-cooked, undercooked, or sunny-side up eggs for all residents. 2. Review of the medical record for Resident #26 revealed an admitted [DATE] with diagnoses of Alzheimer's disease, dementia, and depression. Review of the quarterly MDS assessment, dated 12/21/24, revealed Resident #26 had impaired cognition and required set-up or clean-up assistance with meals. Further review of the physician order dated 07/17/24 revealed Resident #26 received a regular diet with soft and bite sized textures. Review of the medical record for Resident #49 revealed an admitted [DATE] with diagnoses of dementia and chronic pain. Review of the quarterly MDS assessment,t dated 11/21/24, revealed Resident #49 had impaired cognition and required set-up or clean-up assistance for eating. Further review of the physician order dated 02/14/25 revealed Resident #49 received a regular diet with regular textures. Observation during the noon meal service on 02/24/25 at 11:12 A.M. revealed Certified Nursing Assistant (CNA) #458 sitting at a table in the dining room with residents who required cuing and assistance with meals. A bottle of hand sanitizer and a box of disposable gloves were on the table. CNA #458 performed hand hygiene but did not put on disposable gloves before encouraging Resident #26 to eat a cut-up sandwich. CNA #458 picked up the plate and verbally continued to encourage Resident #26 to pick up a piece of sandwich. Resident #26 began to pick up a piece of sandwich, but found it was stuck to another piece, and CNA #458 held the piece of sandwich with her bare hands so Resident #26 could separate the two pieces. Continued observation on 02/24/25 revealed at 11:31 A.M., Resident #29, who was sitting at another table, began calling out. CNA #458 walked over to Resident #29 and attempted to calm him. CNA #458 was not wearing disposable gloves. After CNA #458 was unable to calm Resident #29, she used the telephone to call another staff to remove Resident #29 from the dining room and provide his meal elsewhere. Further observation revealed CNA #458 returned to Resident #29 and again attempted to calm him by touching his arm with one hand while the other hand touched his wheelchair. Continued observation revealed CNA #458 then returned to her chair at the table, did not perform hand hygiene, and picked up silverware and attempted to feed Resident #49. Interview on 02/24/25 at approximately 11:35 A.M. with CNA #458 confirmed she touched Resident #26's sandwich with her bare hand, and further confirmed she touched the telephone, then Resident #29, and did not perform hand hygiene before beginning to assist Resident #49 with eating. CNA #458 confirmed Resident #49 required total assistance with eating. Finally, CNA #458 confirmed she should have donned gloves before touching Resident #26's sandwich and should have sanitized her hands after touching the telephone and Resident #29 before beginning to assist Resident #49 with her meal. Interview on 02/27/25 at 10:00 A.M. with MDS Director #515 revealed Resident #49 had a change in condition mid-February 2025 and was dependent on staff for eating. MDS Director #515 confirmed this was a change from the quarterly MDS assessment completed 11/21/24 when Resident #49 only required set-up assistance. Review of the policy titled Infection Control - Handwashing, revised 03/16/20, revealed no guidance regarding hand hygiene while providing assistance to residents during meals. Review of the policy titled, Food Service - Personal Hygiene, revised 06/27/18, revealed no guidance regarding hand hygiene while providing assistance to residents during meals. Interview on 02/27/25 at 2:50 P.M. with the Director of Nursing (DON) revealed the facility had no policy regarding cleansing hands between residents when providing meal assistance or hand hygiene regarding touching ready-to-eat foods.

Based on review of the facility submitted self-reported incidents (SRI), staff interview and review of the facility policy, the facility failed to ensure thorough investigations were completed. This affected six (#30, #31, #43, #45, #52, and #56) of six residents reviewed for thorough facility investigations. The facility census was 65. Findings include: 1. Review of the facility submitted SRI, created on 11/04/24 at 10:46 A.M., revealed an allegation of physical abuse involving Resident #45 and Resident #30. Review of the corresponding facility investigation revealed no evidence a thorough investigation was completed, including staff interviews, witness statements, like resident interviews/assessments, or any staff education. 2. Review of the facility submitted SRI, created on 11/25/24 at 8:18 A.M., revealed an allegation of physical abuse involving Resident #56 and Resident #43. Review of the corresponding facility investigation revealed no evidence a thorough investigation was completed, including staff interviews, witness statements, like resident interviews/assessments, or any staff education. 3. Review of the facility submitted SRI, created 12/01/24 at 8:55 A.M., revealed an allegation of physical abuse involving Resident #54 and Resident #31. Review of the corresponding facility investigation revealed no evidence a thorough investigation was completed, including staff interviews, witness statements, like resident interviews/assessments, or any staff education. 4. Review of the facility submitted SRI, created 01/17/25 at 9:32 A.M., revealed an allegation of physical abuse involving Resident #31 and Resident #56. Review of the corresponding facility investigation revealed no evidence a thorough investigation was completed, including staff interviews, witness statements, like resident interviews/assessments, or any staff education. Interview on 02/27/25 at 2:03 P.M. with the Administrator verified the facility investigations related to the identified SRIs included no staff interviews, witness statements, like resident interviews/assessments, or evidence of any staff education completed. Interview on 02/27/25 at 2:20 P.M. with the Director of Nursing (DON) confirmed no staff education was completed related to any of the identified SRIs. Review of the facility policy titled, Abuse and Neglect, revised August 2023, revealed the facility would complete an internal investigation of the incident; have evidence that all alleged violations were thoroughly investigated and document all pertinent information. When a resident to resident abuse was reported, the residents would be removed from the situation and assessments completed, the charge nurse would write a written statement providing all factual events as possible and an investigation would be conducted.

Based on medical record review, staff interview and review of the facility bowel protocol, the facility failed to implement bowel interventions. This affected two (#24 and #52) of two residents reviewed for bowel protocol. The facility census was 65. Findings include: 1. Review of Resident #24's medical record revealed and admitted [DATE]. Diagnoses included dementia, major depressive disorder, myocardial infarction (heart attack) of unspecified site, and weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/18/25, revealed Resident #24 was cognitively impaired, required substantial/maximal staff assistance with toileting and was frequently incontinent. Review of the care plan, dated 02/06/25, revealed Resident #24 was at risk for constipation due to impaired mobility. Interventions included administer stool softeners and laxatives as ordered, follow facility bowel protocol for bowel management, monitor medications for side effects of constipation and keep the physician informed of any problems. Review of the February 2025 physician orders revealed Resident #24 was ordered Senna oral tablet 8.6 milligrams (mg) one time a day for constipation from 02/01/25 through 02/12/25. On 02/13/25, Senna Plus oral tablet 8.5 mg-50 mg one tablet by mouth one time per day for constipation was added. Additionally, Resident #47 had orders for milk of magnesium oral suspension 400 mg/5 milliliters (ml), 30 ml by mouth daily as needed for constipation and docusate sodium oral capsule 100 mg, give one by mouth as needed for constipation. Further review revealed an order dated 02/24/25 for Dulcolax rectal suppository 10 mg, insert one suppository rectally as needed for constipation. Review of the bowel elimination record from 01/27/25 to 02/25/25 revealed no evidence Resident #24 had a bowel movement from 02/09/25 through 02/12/25 (four days), from 02/14/25 through 02/17/25 (four days) and 02/20/25 through 02/23/25 (four days). Review of the Medication Administration Record (MAR) for February 2025 revealed Resident #47 received no ordered as needed medications for constipation. 2. Review of Resident #52's medical record revealed an admitted [DATE]. Diagnoses included dementia, major depressive disorder, and chronic kidney disease. Review of the quarterly MDS assessment, dated 12/28/24, revealed Resident #54 was cognitively impaired, was frequently incontinent of bowel and bladder, required substantial/maximal staff assistance with toileting and received hospice care. Review of the care plan, dated 02/20/25, revealed Resident #52 was at risk for constipation related to decreased mobility. Interventions included to administer stool softeners and laxatives as ordered, follow facility bowel protocol for bowel management, monitor medications for side effects of constipation, and monitor/document/report as needed signs and symptoms of complications related to constipation. Review of the current physicians orders revealed Resident #52 was ordered Miralax oral packet 17 grams (gm), give one packet one time a day, every other day, for constipation. Additionally, Resident #52 had orders for milk of magnesia oral suspension 400 mg/5 ml, give 30 ml by mouth as needed for constipation every other day if no bowel movement in three days and bisacodyl laxative rectal suppository 10 mg, insert one suppository rectally as needed for constipation daily. Review of bowel elimination record from 01/27/25 to 02/25/25 revealed no evidence Resident #52 had a bowel movement from 02/11/25 through 02/14/25 (four days) and 02/16/25 through 02/19/25 (four days). Review of the MAR for February 2025 revealed Resident #52 received no additional ordered as needed medications for constipation. Interview on 02/25/25 at 3:10 P.M. with the Director of Nursing (DON) confirmed there was no evidence Resident #24 had a bowel movement from 02/09/25 through 02/12/25, 02/14/25 through 02/17/25 and 02/20/25 through 02/23/25. Additionally, the DON verified there was no evidence Resident #52 had a bowel movement from 02/11/24 through 02/14/25 and 02/16/25 through 02/19/25. The DON further verified no additional bowel interventions were implemented for Resident #24 and Resident #52. Interview on 02/26/25 at 11:43 A.M. with Licensed Practical Nurse (LPN) #438 revealed the facility bowel protocol included the administration of milk of magnesia and, after three days of no bowel movement, a suppository would be given. LPN #438 stated interventions would be documented on the MAR. Interview on 02/26/25 at 11:46 A.M. with Certified Nurse Aide (CNA) #474 confirmed bowel movements were documented on the bowel elimination record. Review of the facility document titled, Bowel Protocol Per Medial Director, revised 10/30/19, revealed if there was no documentation of a bowel movement in three days, administer bisacodyl suppository 10 mg rectally every other day as needed.

Based on observation, staff interview and review of the facility policy, the facility failed to ensure medications were not left at the bedside. This affected one (#47) of one resident reviewed for medication storage. The facility identified five (#22, #25, #33, #55, and #56) additional residents who were cognitively impaired and independently mobility residing on the 800-Hall. The facility census was 65. Findings include: Review of the medical record for Resident #47 revealed an admitted [DATE]. Diagnoses included dementia. Review of the annual Minimum Data Set (MDS) assessment, dated 12/17/24, revealed Resident #47 was mildly cognitively impaired. Review of the current physician orders for February 2025 revealed Resident #47 was not prescribed Tums (antacid). Additional review revealed no order for self-administration of medication. Further review of the medical record revealed no evidence Resident #47 had been assessed for self-administration of medication. Observation on 02/24/25 at 2:02 P.M. of Resident #47's room revealed a bottle of Tums at the resident's bedside. A warning label on the Tums bottle read to Keep out of reach. Concurrent interview with Resident #47 revealed her son bought the bottle of Tums for her. Interview on 02/24/25 at 2:14 P.M. with Registered Nurse (RN) #509 verified the bottle of Tums at Resident #47's bedside and confirmed they should not have been there. Interview on 02/26/25 at 2:00 P.M. with the Director of Nursing (DON) revealed five additional residents (#22, #25, #33, #55, #56) resided on the 800-Hall and were cognitively impaired and independently mobile. A follow-up interview on 02/27/25 at 1:17 P.M. with the DON and verified Resident #47 did not have a physician order for Tums until 02/25/25.

Based on medical record review, observation and staff interview, the facility failed to ensure privacy curtains were maintained in good repair. This affected two residents (#3 and #29) of two residents reviewed for privacy curtains. The facility census was 65. Findings include: 1. Review of the medical record Resident #3 revealed an admitted [DATE] with diagnoses of cerebral vascular accident (CVA) and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/31/24, revealed Resident #3 was cognitively intact. Observation on 02/24/25 at 2:22 P.M. of Resident #3's room revealed the privacy curtain in the semi-private room was in disrepair and ripped at the top. Further observation revealed binder clips were used to hold the curtains together. Concurrent interview with Resident #3's daughter revealed the curtain had been like that the entire time the resident resided in that room, adding she reported it and requested it be repaired. Interview on 02/24/25 at 2:30 P.M. with Hospitality Aide (HA) #507 verified the ripped privacy curtain and verified binder clips were used to hold the curtain together. 2. Review of the medical record for Resident #29 revealed an admitted [DATE] with diagnoses of atrial fibrillation, transient ischemic attack (TIA), and anxiety. Review of the quarterly MDS assessment, dated 01/05/25, revealed Resident #29 was cognitively impaired. Observation on 02/24/25 at 11:23 A.M. of Resident #29's room revealed the resident resided in a semi-private room and the privacy curtain was ripped at the top and hanging onto the floor. Interview on 02/24/25 at 2:31 P.M. with HA #507 verified the privacy curtain in Resident #29's room was ripped at the top and hanging onto the floor. Interview on 02/25/25 at 4:44 P.M. Director of Nursing (DON) revealed the facility did not have a policy for homelike environment.

Based on observation, medical record review and staff interview the facility failed to ensure call lights were within reach and accessible to residents. This affected one (#52) of one resident reviewed for call lights. The facility census was 65. Findings include: Review of the medical record revealed Resident #52 was admitted on [DATE]. Diagnoses included dementia, major depressive disorder and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/28/24, revealed Resident #52 was frequently incontinent of bowel and bladder, required substantial/maximal staff assistance with toileting and received hospice care. Observation on 02/24/25 at 9:54 A.M. revealed Resident #52 was sitting in a chair in her room, watching television. Further observation revealed the resident's call light was wrapped around side rail of the bed, approximately three feet from the resident, and was not within Resident #52's reach. Interview on 02/24/25 at 9:54 A.M. with Certified Nursing Assistant (CNA) #519 revealed Resident #52 was able to express care needs and utilized the call light for assistance. CNA #519 verified Resident #52's call light was not within the resident's reach and further confirmed call lights should be accessible to residents.

Based on record review, staff interview, review of the facility's Self-Reported Incidents (SRI), and policy review, the facility failed to report an allegation of physical and verbal abuse of a resident to the State Survey Agency, the Ohio Department of Health (ODH). This affected one (Resident #68) of three residents reviewed for abuse. The facility census was 68. Findings include: Review of Resident #68's medical record revealed an admitted [DATE]. Diagnoses included Parkinson's disease, dementia, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 had a low cognitive function and required a two-person assist for all activities of daily living (ADL) except eating. Review of the Administrator's investigation dated 06/28/23 revealed a Housekeeper reported an employee sitting in front of Resident #68 with their legs positioned over the recliner, in order to not allow Resident #68 to get up. The Housekeeper also reported another employee called Resident #68 crazy in front of Resident #68. Review of the facility's SRIs dated 06/28/23 to 08/06/23 revealed there was no allegation of physical and verbal abuse of Resident #68 reported to ODH. Interview with the Administrator on 08/07/23 at 2:24 P.M. revealed on 06/28/2,3 he received an allegation of abuse from a housekeeper regarding employees abusing Resident #68. The Administrator stated he completed an investigation and made a decision that it was unsubstantiated within 24 hours so felt he did not need to report the allegation of abuse to ODH. Review of the facility policy titled Abuse and Neglect, revised 11/01/22, revealed Hillsdale Country Living will report all allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property immediately, but not later than two hours after the allegation is made, if the event that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events do not result in serious bodily injury to the Administrator of the facility and to other officials (ODH) in accordance with State law through established procedures. Following an investigation, a finalized report will be submitted to the ODH within five working days of the initial report. This deficiency represents non-compliance investigated under Complaint Number OH00144651.

Based on record review, staff interview, review of the facility's Self-Reported Incidents (SRI), and policy review, the facility failed to implement their abuse policy when an allegation of physical and verbal abuse of a resident was not reported to the State Survey Agency, the Ohio Department of Health (ODH) and the facility did not not notify the family/Power of Attorney (POA) of the abuse allegation. This affected one (Resident #68) of three residents reviewed for abuse. The facility census was 68. Findings include: Review of Resident #68's medical record revealed an admitted [DATE]. Diagnoses included Parkinson's disease, dementia, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 had a low cognitive function. Review of the Administrator's investigation dated 06/28/23 revealed a Housekeeper reported an employee sitting in front of Resident #68 with their legs positioned over the recliner, in order to not allow Resident #68 to get up. The Housekeeper also reported another employee called Resident #68 crazy in front of Resident #68. There was no documentation in the medical record or the Administrator's investigation dated 06/28/23 that the family/POA was no notified of the allegations of abuse involving Resident #68. Review of the facility's SRIs dated 06/28/23 to 08/06/23 revealed there was no allegation of physical and verbal abuse of Resident #68 reported to ODH. Interview with the Administrator on 08/07/23 at 2:24 P.M. revealed on 06/28/23 he received an allegation of abuse from a housekeeper regarding employees abusing Resident #68. The Administrator stated he completed an investigation and made a decision that it was unsubstantiated within 24 hours so felt he did not need to report the allegation of abuse to ODH. Interview with the Director of Nursing (DON) on 08/08/23 at 2:29 P.M. verified the facility did not notify Resident #68's family/POA of the abuse allegations involving Resident #68. Review of the facility policy titled Abuse and Neglect, revised 11/01/22, revealed Hillsdale Country Living will report all allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property immediately, but not later than two hours after the allegation is made, if the event that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events do not result in serious bodily injury to the Administrator of the facility and to other officials (ODH) in accordance with State law through established procedures. Following an investigation, a finalized report will be submitted to the ODH within five working days of the initial report. Notify the resident representative, as applicable, as soon as possible. This deficiency represents non-compliance investigated under Complaint Number OH00144651.

Based on observation, staff interview, review of the dishwasher temperature log, and review of the facility's policy, the facility failed to ensure the dishwashing machine maintained the appropriate temperature for effective sanitation. This had the potential to affect 64 residents who resided in the facility and received food from the kitchen. Resident #41 received no food by mouth and thus no food from the kitchen. The facility census was 65. Findings include: Observation on 10/24/22 at 10:24 A.M. of the dishwasher in the kitchen washroom revealed the dishwasher was a high temperature dishwasher. The sticker on the outside of the machine indicated the dishwasher needed to reach 180 degrees Fahrenheit (F) during the rinse cycle. The dishwasher was in use with three trays of silverware, cups, and plates on the clean side of the dishwasher drying in racks. Dietary Manager (DM) #430 ran another rack through and observation of the rinse cycle revealed it only reached 178 degrees F. Interview on 10/24/22 at 10:25 A.M. with DM #430 verified the dishwasher did not reach the proper temperature for sanitation. DM #430 reported they had been having trouble with the dishwasher and it took three or four runs before it would get up to temperature. DM #430 ran the dishwasher again and it only reached 178 degrees F. Observation and interview on 10/24/22 at 10:27 A.M. of the dishwasher being run with a thermometer disk and a temperature strip with DM #430 revealed the thermometer disk read 148 degrees F after the cycle was complete and the sticker continued to be white and had not turned black indicating it has not reached the appropriate temperatures. DM #430 verified even after running three times, the dishwasher was not reaching the appropriate temperature for sanitation. DM #430 stated maintenance would be notified and advised the staff to use the three sink system until the dishwasher was repaired. Observation on 10/25/22 at 8:56 A.M. of the kitchen dishwasher found it was in use. Three trays of plates, cups and bowls were observed on the clean side of the dishwasher and were being put away or added to the drying rack by Dietary Staff (DS) #423. Observation on 10/25/22 at 8:58 A.M. of the wash temperature of the dishwashing machine for the fourth rack run through, found the temperature reached only 176 degrees F during the rinse cycle. Interview on 10/25/22 at 8:59 A.M. with DM #430 verified the temperature had reached only 176 degrees F. DM #430 reported maintenance cleaned the temperature probes yesterday and it had been working fine afterwards. DM #430 ran the dishwasher again and it reached only 178 degrees F. The dishwasher was run again and only reached 178 degrees F during the rinse cycle. Observations on 10/25/22 at 9:14 A.M. with DS #419 revealed DS #419 was removing dishes from the dishwasher racks and putting them away. The temperature was observed reaching 178 degrees F and the three sink system was not in use. At 9:18 A.M., DS #419 was inspecting cups for cleanliness. DS #419 was observed putting one back on the dirty side of the dishwashing machine to be washed again. All other cups were added to the drying rack. The three sink system was not in use. The temperature was observed reaching 176 degrees F. Interview on 10/25/22 at 9:25 A.M. with DS #419 revealed the facility used the three sink system for bigger pans and steam table trays. DS #419 stated they ran plates and cups through the dishwasher on racks. DS #419 verified he had ran a few racks through the dishwasher this morning and they had already been put away. Observation on 10/25/22 at 11:06 A.M. of DS #412 revealed she was in the dishwashing room instructing the other staff to not use the dishwasher until it was repaired. A maintenance staff was overheard verifying the dishwasher was broken and should not be used until it was repaired. Interview on 10/25/22 at 1:19 P.M. with DM #430 revealed the maintenance staff contacted a repair company who evaluated the dishwasher. DM #430 verified there was a bad thermostat which was being replaced. Review of the facility's dishwashing log for the months of August 2022, September 2022, and October 2022 revealed on 08/23/22 the dishwasher began not consistently maintaining appropriate dishwasher rinse temperatures. From 08/01/22 through 10/23/22, there were 58 times the dishwasher was recorded as being below the required 180 degree F during the rinse cycle. No record of temperature was documented for 20 days during this time frame. The following 20 dates had no dishwasher temperatures recorded: on 08/26/22, 09/02/22, 09/03/22, 09/04/22, 09/10/22, 09/12/22, 09/13/22, 09/18/22, 09/23/22, 09/24/22, 09/26/22, 09/27/22, 09/29/22, 10/02/22, 10/06/22, 10/09/22, 10/10/22, 10/12/22, 10/15/22, and 10/16/22. Review of the facility's policy titled Food and Nutritional Service-Machine Dishwashing, revised 05/18/21, revealed the machine dishwashing would be conducted in accordance with the directions of the dishwashing machine's manufacturer. The temperatures of the machine's wash and rinse cycle was to be 150 degrees F during the wash and 180 degrees F during the final rinse.

Based on review of the facility's staff vaccination COVID-19 log, staff interview, review of the facility's policy, and review of the Centers of Medicare and Medicaid Services (CMS) memorandum QSO-23-02-ALL, the facility failed to ensure staff were COVID-19 vaccinated, had an approved exemption, or had been identified as appropriate for a temporary delay per Center for Disease Control and Prevention (CDC) guidance. The vaccination rate for the facility was calculated at 74%. This had the potential to affect all 65 residents currently residing in the facility. Findings include: Review of the Staff Vaccination COVID-19 log, provided on 10/24/22, revealed the facility had 104 employees with 60 employees vaccinated, 17 employees with a religious exemption, and 27 employees with neither a COVID-19 vaccination, approved exemption, or temporary delay. Interview on 10/26/22 at 2:48 P.M. with the Administrator revealed the employees have the choice to receive the vaccination, have an exemption, or neither. The Administrator stated he decided not to have facility employees in an ethical dilemma and does not require employees to have the COVID-19 vaccination or a valid exemption. Review of the Centers for Medicare & Medicaid Services (CMS) memorandum, QSO-23-02-ALL regarding COVID-19 health care staff vaccination, dated 10/26/22, revealed CMS expects all providers' and suppliers' staff to have received the appropriate number of doses of the primary vaccine series unless exempted as required by law, or delayed as recommended by the Centers for Disease Control and Prevention (CDC). Facility staff vaccination rates under 100% constitute noncompliance under the rule. Review of the facility's policy titled COVID-19 Immunization Policy, last revised 08/01/22, revealed in November 2021, CMS regulated all healthcare workers are required to be COVID-19 vaccinated as a Condition of Participation (COP) regarding Medicare and Medicaid Funding. Prior to 12/06/21, as well as upon or prior to hire, the facility will determine if an employee has had the recommended vaccinations. Those who have not received the recommended vaccinations will be provided with education upon hire and given the opportunity to receive the vaccine, if consent is received, arrangements will be made. Employees have the right to decline or claim exemptions from the COVID-19 vaccine based upon medical exemption and sincere religious belief, practice, or observation.

Based on medical record review, review of the facility's Self-Reported Incidents (SRI), staff interview, and review of the facility's policy, the facility failed to report an allegations of abuse to the State Survey Agency. This affected one (Resident #35) of 24 residents reviewed for abuse. The facility census was 65. Findings include: Review of Resident #35's medical record revealed Resident #35 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 08/17/22, revealed Resident #35 was moderately cognitively impaired. Review of Resident #35's initial skin assessment dated [DATE] revealed there were no identified bruises to Resident #35's arms or wrists. Review of Resident #35's progress notes, dated 08/15/22, revealed the facility was notified by a hospice nurse that Resident #35 had two bruises that were not observed last week. Resident #35 had stated a man was in her room and attacked her which resulted in the bruises. The bruise on the right arm measured 13 centimeters (cm) in length by 11 cm wide and was dark purple in color with yellow around the edges. Bruise on the left wrist measured 7.0 cm by 7.5 cm and were dark purple in color. Review of the progress notes, dated 08/15/22, revealed the facility talked to the family regarding the resident's bruises on the right arm and left wrist. Resident #35's daughter stated she was aware of the bruises prior to admission. Review of the facility's SRIs, dated from 08/11/22 through 10/25/22, revealed there was no SRI completed for the allegation of abuse involving Resident #35. Interview on 10/26/22 at 1:42 P.M. with Registered Nurse (RN) #462 revealed on an unknown date, a hospice nurse reported to her that Resident #35 had reported the bruises were noted on the resident's arms and the Resident #35 reported she was grabbed. Telephone interview on 10/26/22 at 3:18 P.M. with Hospice RN #504 revealed there was a hospice note that a hospice Licensed Practical Nurse (LPN) #505 was at the facility on 08/16/22 and noted bruising to the right upper arm and left forearm. RN #504 stated Resident #35 was known to make false allegations. Interview on 10/26/22 at 2:00 P.M. with the Administrator verified an SRI was not completed for the allegation of abuse with Resident #35. The Administrator reported the facility was able to quickly unsubstantiate the allegation and did not enter the information as required. Review of the facility's policy titled Abuse and Neglect, last reviewed 07/22/21, revealed the facility will report all allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of the resident property immediately, but not later than two hours after the allegation is made, if the even that cause the allegation involve abuse or result in serious bodily injury , or not later than 24 hours if the events do not result in serious bodily injury to the Administrator of the facility and to other officials (ODH) in accordance with state law through established procedures. The Administrator, Director of Nursing, or designee will contact the Ohio Department of Health and law enforcement if appropriate. All allegations, even those proven unsubstantiated, must be reported.

Based on medical record review, observations, and staff interview, the facility failed to ensure residents who required assistance from staff with activities of daily living (ADL) received adequate and timely assistance with grooming. This affected two (Resident #19 and #48) of two residents reviewed for ADL care. The facility identified all 65 residents required assistance from staff with bathing and 64 residents required assistance from staff with dressing. The facility census was 65. Findings include: 1. Review of Resident #48's medical record revealed Resident #48 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment revealed Resident #48 was severely cognitively impaired and required one person extensive assistance with personal hygiene. Observations on 10/24/22 at 2:59 P.M., on 10/25/22 at 4:17 P.M., and on 10/26/22 at 9:15 A.M. revealed Resident #48 was observed in the common area with a heavy medium length white stubble above her upper lip. Interview on 10/26/22 at 9:18 A.M. with State tested Nursing Assistant (STNA) #503 revealed Resident #48 was compliant with care, has never refused care, and required assistance with personal hygiene. STNA #503 stated she had noticed heavy facial hair on the female resident previously. STNA #503 verified Resident #48's facial hair was obvious and in need of trimming. 2. Review of Resident #19's medical record revealed Resident #19 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment, dated 07/26/22, revealed Resident #19 was severely cognitively impaired. Resident #19 required one person extensive assistance with personal hygiene. Observation on 10/26/22 at 9:28 A.M. revealed Resident #19 had numerous long (approximately one-fourth to half inch long) facial hair on the chin. Interview on 10/16/22 at 9:28 A.M. with STNA #485 verified Resident #19 was in need of grooming for facial hair.

Based on observation, resident interview, staff interview, medical record review, review of the Weather Channel's weather report, and review of the facility's policy, the facility failed to ensure residents were provided consistent individualized activities of their choice to meet their interests and psychosocial needs. This affected one (Resident #3) of one resident reviewed for choices. The facility census was 65. Findings include: Review of Resident #3's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eight indicating Resident #3 was moderately cognitively impaired. Resident #3 required extensive assistance with bed mobility, transfer, dressing, and personal hygiene. Resident #3 displayed no behaviors during the review period. Resident #3 was not receiving [CONDITION(S)] or [CONDITION(S)] at the time of the review. Review of Resident #3's care plan revised 10/05/22 revealed supports and interventions for pain, risk for alteration in mood, risk for falls, and participation in actives included going outside. Interventions included all staff to converse with the resident while providing care, invite resident to scheduled activities, assist the resident with activities of daily living as required during the activity, escort to activity functions, self-care deficit, and provide activities of interest and empowers the resident by encouraging and allowing choice, self-expression and responsibility. Review of Resident #3's State tested Nursing Assistant (STNA) Tasks for the last 30 days revealed activity programming for outside activities was included under the social activities task. Resident #3 was noted to have gone outdoors on 10/02/22. This was the only outdoor activity found for the last 30 days. Further review revealed Resident #3 went out on an outing with his family on 10/15/22 and 10/23/22. Resident #3 also went out to eat with the facility on 10/17/22. Review of Resident #3's progress notes revealed on 10/19/22 a care plan meeting was held and Resident #3's activity participation was discussed. It was noted Resident #3 liked going outside in nice weather and staff would continue to invite Resident #3 to a variety of activities of his choice. Observation on 10/24/22 at 10:48 A.M. revealed Resident #3 sitting up in his wheelchair in the front of the facility looking out the glass doors. Resident #3 was clean, dressed, and aware. The weather outside was sunny and in the high sixties. Interview on 10/24/22 at 2:32 P.M. revealed Resident #3 was alert and aware. Resident #3 reported he had no concerns for care other than he would like to go outside and he couldn't. Resident #3 stated the weather was nice but there was no one who would take him outside and he was not allowed to go by himself. Resident #3 reported he didn't like the rule that said he could not go outside by himself. Resident #3 stated the staff were busy and were not able to take him outside when he wanted to go. Resident #3 stated he had told the staff today he wanted to go outside but he had been waiting all day and no one had had time to take him. The weather outside was sunny and in the seventies. Observation throughout the morning on 10/25/22 revealed Resident #3 was up in his wheelchair moving around the facility. Resident #3 was not observed being taken outside. The weather was partially cloudy and in the seventies. Interview on 10/25/22 at 2:22 P.M. with Resident #3 revealed Resident #3 thought it looked nice outside but he had not been able to go outside. Resident #3 stated he wanted to go outside whenever the weather was nice because it wasn't going to be nice for much longer. Interview on 10/26/22 at 9:41 A.M. with Activity Director (AD) #405 revealed one of Resident #3's favorite things to do was to go outside. AD #405 reported they would take Resident #3 outside individually when the weather was nice. AD #405 reported Resident #3 was not able to go out by himself for safety reasons so he had to have staff with him. AD #405 reviewed the list of outdoor activities Resident #3 participated in and verified he had not been taken outside since 10/02/22 and verified the weather had been nice for the past couple days. Interview on 10/26/22 at 11:18 A.M. with State tested Nursing Assistant (STNA) #469 revealed Resident #3 was able to make his needs known and really enjoyed going outside when the weather was nice. STNA #469 reported the STNAs provided direct care and the activity department were the staff responsible for assisting Resident #3 outside when he wanted to go. Review of the Weather Channel's temperature history for the local area revealed on 10/24/22, the highest temperature for the day was 77 degrees Fahrenheit (F) and the lowest temperature at night was 53 degrees F. On 10/25/22, the highest temperature for the day was 75 degrees F and the lowest temperature at night was 56 degrees F. Review of the facility's policy titled Resident Rights, revised 11/28/16, revealed the residents had the right to a dignified existence and self determination. The resident had the right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Based on resident interview, family interview, medical record review, staff interview and review of the facility's policy, the facility failed to ensure residents and their representatives were properly notified of scheduled care conference meetings so they had the opportunity to attend. This affected one (Resident #59) of 19 residents whose care plans were reviewed. The facility census was 65. Findings Include: Review of Resident #59's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #59's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating Resident #59 was moderately cognitively impaired. Resident #59 required limited assistance bed mobility, and transfer. Resident #59 required extensive assistance with dressing, toilet use and personal hygiene. Resident #59 displayed no behaviors during the review period. Review of Resident #59's care plan revised 10/24/22 revealed supports and interventions for potential for risk for decline in mood, self-care deficit, risk for falls, and potential for pain. Review of Resident #59's Care Plan Meeting forms revealed care plan meetings were held on 08/25/22 and 09/06/22. Neither Resident #59 nor his Power of Attorney (POA) were in attendance. Four facility staff were in attendance on 08/25/22 and six facility staff were in attendance on 09/06/22. Further review of Resident #59's record revealed there were no invitations or notifications to Resident #59 or his POA for either meeting. Review of Resident #59's progress notes revealed on 09/01/22, it was noted a care conference was held on 08/25/22. The note reported neither Resident #59 nor his POA were present. It stated Resident #59's POA was updated following the conference and a copy of Resident #59's care plan was offered but declined. During the care conference, it was noted the facility staff discussed diet, weight, activity participation, activity of daily living status, restorative information, and Resident #59's medication. Resident #59 had a Do Not Resuscitate Comfort Care Arrest (DNRCCA) code status, and the facility had his living will and documentation of POA on file. Resident #59 was noted to be in the facility for long term care. Further review of Resident #59's progress notes revealed on 09/06/22, it was noted Resident #59's Entry Care Conference was held on 09/06/22. Neither Resident #59 nor his POA were present. It stated Resident #59's POA was updated following the conference and a copy of Resident #59's care plan was offered but declined. During the care conference, it was noted the facility staff discussed diet, weight, activity participation, activity of daily living status, restorative information, and Resident #59's medication. Resident #59 had an appointment with urology on 09/19/22 at 10:40 A.M. and 09/19/22 at 1:00 P.M. with cardiology. Interview on 10/24/22 at 1:23 P.M. with Resident #59 revealed he was alert and oriented. Resident #59 reported he was not invited to care plan meetings. Resident #59 reported he did not get to attend those. Interview on 10/27/22 at 8:42 A.M. with Social Services Director (SSD) #408 revealed letters were sent out to families a couple weeks prior with the date and time of the care conference. SSD #408 was unable to provide evidence notification was provided to Resident #59 or his representative prior to the care conference being held. SSD #408 provided a blank standard form as a copy of what was sent out. SSD #408 verified neither Resident #59 nor his representative were in attendance at either of his care planning meetings. Interview on 10/27/22 at 10:34 A.M. with Resident #59's daughter revealed she was verbally told of the care planning meeting to be held in September 2022 when her father moved from the assisted living to the nursing home in August 2022. She was not informed of a care conference being held in August 2022. Resident #59's daughter reported she never received a reminder for the September 2022 meeting and thus her and her father did not attend. Resident #59's daughter verified she was her father's POA and they would have liked to have participated. Review of the facility's policy titled Care Conference, revised 03/22/16, revealed the residents would have an opportunity to discuss their desired preferences and goals. On the day of the conference, a member of the Interdisciplinary Team would invite the resident to attend the meeting. The resident's responsible party would be notified of the scheduled care conference via letter format. This would be an invitation for the responsible party to call and set up an appointment to attend the care conference meeting.

Based on review of medical record, observation, staff interviews, review of facility policy, and review of Center for Disease Control (CDC( Guidelines Strategies for Optimizing the supply of N-95 Respirators, the facility failed to ensure N-95 masks, which were approved for limited re-use, were not discarded per CDC recommendation. Additionally the facility failed to ensure N-95 masks used by staff on a quarantine unit, did not further potentially expose residents to COVID-19. This directly affected two residents (#02, and #03) of three residents reviewed for infection control and had the potential to affect all residents who resided in the facility except for Resident #01, who was on a separate COVID-19 unit. The facility census was 60. Findings include: 1. Review of the medical record for Resident #02 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. restless leg syndrome, depression, dry eye syndrome, [MEDICAL CONDITIONS] atrophy, anxiety, mood disorder, left shoulder pain, abnormal posture, asthma, rotator cuff tear, [DIAGNOSES REDACTED] (sudden temporary onset) [MEDICAL CONDITION], dysphagia (trouble swallowing). Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident required extensive assistance with bed mobility, locomotion, dressing, toileting, and personal hygiene, was totally dependent for transfers and supervision for eating. The MDS further revealed the resident was frequently incontinent of urine and was short of breath. Review of physician orders [REDACTED]. Observation of the room for Resident #02 on 01/11/21 at 1:30 P.M. revealed signage was present on the door to the room to alert staff of the need to wear specific Personal Protective Equipment (PPE) while in the room, including N-95 masks. 2. Review of the medical record for Resident #03 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]., gastro-[MEDICAL CONDITION] reflux disease, [MEDICAL CONDITION], dysphagia (difficulty swallowing). Review of a comprehensive annual MDS 3.0 assessment dated [DATE] revealed the resident had moderate cognitive impairment. Extensive assistance was required for bed mobility, dressing, personal hygiene and the resident was totally dependent for transfers, locomotion and toileting. An indwelling catheter was present and the resident was frequently incontinent of bowels. Review of progress notes dated 01/06/21 revealed the resident was to be in Quarantine for 14 days due to possible exposure to COVID-19. Observation of the room for Resident #03 on 01/11/21 at 1:25 P.M. revealed signage was present on the door to the room to alert staff of the need to wear specific PPE while in the room, including N-95 masks. Further observation on 01/11/21 at 1:30 P.M. revealed State tested Nursing Assistant (STNA) #15 and Licensed Practical Nurse (LPN) #20 went into the room of Resident #02, who was on droplet precautions with a gown, N-95, goggles and gloves. The two staff members were observed coming out of the resident room at 1:42 P.M., rubbing their hands together in a cleansing motion. The gown had been removed and discarded prior to exiting the room. The N-95 mask and goggles were still in place. Both staff members were observed to enter the room of Resident #03 on 01/11/21 at 1:43 P.M. The staff members were observed donning a new gown and gloves. Observation of Laundry Staff (LS) #25 on 01/11/21 at 1:40 P.M. revealed the employee was delivering laundry to residents on the 500 hall (quarantine hall). Laundry staff #25 was observed going in and out of resident rooms which had signage on the door informing of droplet precautions and the need for PPE. The staff member was observed wearing a gown, gloves, goggles and N-95 mask during her work. She was observed to change gloves after exiting the rooms and took off the gown, but kept the N-95 mask on. The goggles were cleansed with sani-wipes. Interview with STNA #15 on 01/11/21 at 1:45 P.M. verified she had been in two separate resident rooms who were on droplet precautions. She verified she had not changed the N-95 mask between the quarantine and did not have the mask protected with any covering while she was in the rooms. She stated she wore her N-95 for the whole day, regardless of who she took care of, and then placed it in a paper bag for three days before she wore it again. Interview with LPN #20 on 01/11/21 at 1:48 P.M. verified she had been in two quarantine rooms and used the same N-95 mask, with nothing protecting the mask. She stated she had never worn any type of covering over the N-95 masks, such as a face shield of surgical mask, and throughout the day she would leave a room with droplet precautions and go to another hall to assist residents who had not been exposed to COVID-19, with the same N-95 mask. She stated she cleaned her goggles with sani-wipes but did not do anything to her N-95 mask. Interview with LS #25 on 01/11/21 at 1:50 P.M. revealed she had delivered laundry to multiple residents on the quarantine hall. She stated she used the same gown for each room and also the same N-95 mask. She stated she would go in and deliver the laundry and leave. She further verified she had nothing protecting her N-95 while she was in the room of one quarantine resident. Interview with the Director of Nursing on 01/11/21 at 2:00 P.M. verified staff did wear the same N-95 mask throughout the day with multiple residents. She further verified the staff did take care of multiple residents on the quarantine unit, and used the same N-95 mask. She verified the staff did not utilize a face shield, surgical mask or any other covering over the N-95 masks while caring for any of the residents. She further verified the facility used several brands of N-95 masks, due to having issues of getting enough N-95's from any one provider. She stated some of the N-95 masks were discarded at the end of one day and others were placed in a paper bag and re-used one more time after four days had passed. Review of facility policy Plan for coronavirus revised 08/04/20 revealed the facility was to identify outbreak management supply needs and discuss them with Vendors regarding N-95 masks. Strategies for Optimizing the Supply of N-95 Respirators from the CDC additional guidance. A resident with known or suspected COVID-19 was to have immediate infection prevention and control measures put into place. The resident was to be placed in a private room on standard, contact, droplet precautions, and could be cohorted with resident with the same symptoms. Respiratory Protection (Fit-tested National Institute for Occupational Safety and Health (NIOSH) certified disposable N-95 filtering face mask respirators), if available, were to be donned prior to entry and removed after exiting. If a shortage of PPE, the facility would contact the local and state public health agency to notify them of the shortage, follow national guidelines for optimizing their current supply, or identify the next best option to care for residents. Dedicated or disposable patient care equipment should be used. If equipment must be used for more than one resident, it will be cleaned and disinfected before use on another resident according to manufacturer's recommendations. Review of the CDC's recommendations, Strategies for Optimizing the supply of N-95 Respirators dated 11/23/20 revealed under crisis capacity strategies, an N-95 mask was limited to the number of reuses to no more than five uses (five donnings) per device to ensure adequate respirator performance if no manufacturer guidance was available. A crisis capacity was defined as strategies that were not commensurate with U.S. standards of care but may need to be considered during periods of known N-95 respirator shortage. Crisis capacity strategies were only to be implemented after consideration and implementation of conventional and contingency capacity strategies. Facilities could consider crisis capacity when the supply was not able to meet the facility's current or anticipated utilization rate. If extended use (practice of wearing the N-95 mask for repeated close contact encounters with several different patients without removing the mask between patient encounters) of the N-95 was used, the health care provider could consider using a face shield or facemask over the respirator to reduce contamination of the respirator.

Based on observation, staff interviews, and review of facility policy the facility failed to display signage on the room doors of residents who were on transmission based precautions for possible COVID-19 exposure. This had the potential to affect 34 Residents (#101, #102, #104, #106, #107, #108, #110, #111, #114, #115, #117, #118, #120, #122, #123,#125, #127, #130, #132, #135, #137, #138, #140, #141, #143, #147, #148, #151, #154, #155, #157, #158, #160, and #163) on transmission based precautions. The facility census was 63. Findings include: Observation on 12/08/20 from 10:30 A.M. to 10:50 A.M. of Ivy Lane Hall, Morning Glory Hall, and Pleasantview Hall revealed Personal Protective Equipment (PPE) storage bins outside resident room doors for Resident #101, #102, #104, #106, #107, #108, #110, #111, #114, #115, #117, #118, #120, #122, #123,#125, #127, #130, #132, #135, #137, #138, #140, #141, #143, #147, #148, #151, #154, #155, #157, #158, #160, and #163. These residents were on transmission based precautions. There was no signage on resident room doors or signage outside the resident halls to notify staff and visitors these residents were on isolation precautions. Interview on 12/08/20 at 12:02 P.M. with the Administrator verified there was no signage on at the rooms or on the hallways of residents on transmission based precautions. Review of facility policy titled Infection Control-Signage, effective 12/08/20 verified the facility will post signage outside each resident room doorway for residents on droplet precautions.

Based observation, resident interview, visitor interview, and staff interview, the facility failed to maintain comfortable temperatures in the main dining room. This affected seven residents (#13, #30, #47, #6, #272, #59, and #51), as well as a visitor eating lunch in the main dining room. The facility identified 22 residents who were eating lunch in the main dining room. The facility census was 70. Findings include: Observation on 10/15/19 at 11:11 [NAME]M. of the main dining room revealed Resident #13 wrapped in a fleece blanket. The blanket was pulled up to her chin. An interview was attempted with Resident #13, however the resident was not able to respond. Interview on 10/15/19 at 11:13 [NAME]M. with Resident #30, #47 and #6 revealed they were cold and uncomfortable in the dining room. Resident #47 revealed it had been cold in the dining room for over a week and they had been wearing sweaters, and other layers to keep warm. Resident #47 reported they had told the staff, however it was still cold. Observation on 10/15/19 at 11:15 [NAME]M. of the dining room thermostat revealed the temperature was 66 degrees Fahrenheit (F). Interview on 10/15/19 at 11:19 [NAME]M. with Activities Director (AD) #200 verified the temperature in the dining room was 66 degrees (F). AD #200 revealed she did not have a key to unlock the plastic box to adjust the temperature. She was not sure who had the key. Interview on 10/15/19 at 11:23 [NAME]M. with Resident #51, #59, #272, and a visitor revealed it was cold and uncomfortable in the dining room. Resident #59 revealed it had been too cold the dining room for a few days and she had to wear a [NAME]et in the dining room. Resident #59 revealed she wore layers because she was told by staff there was nothing they could do about the temperature. Interview on 10/15/19 at 11:25 [NAME]M. with Dietary Staff (DS) #106 revealed the maintenance staff were the only ones with a key to unlock the thermostat and adjust the temperature. DS #106 verified the dining room was cold and residents were uncomfortable. DS #106 revealed they were not able to make any adjustments themselves. Observation on 10/15/19 at 11:27 [NAME]M. of the main dining room thermostat revealed the temperature was 67 degrees (F). Interview on 10/15/19 at 11:28 [NAME]M. with Maintenance Staff (MS) #150 verified the maintenance staff were the only ones with a key for the dining room thermostat and the temperature was currently 67 degrees (F) in the main dining room. MS #150 revealed the thermostat had not been switched over from cool to heat yet. MD #150 made the adjustment. Observation on 10/15/19 at 5:07 P.M. of the main dining room revealed the thermostat revealed the temperature was 71 degrees (F). Interview on 10/17/19 at 11:20 [NAME]M. with the Director of Nursing (DON) revealed there was no written policy for environmental temperatures. The DON revealed they followed the regulation requirements to maintain temperatures between 71 degrees and 81 degrees (F).

Based on medical record review, review of the facility self reported incident (SRI), resident interview, staff interview, and review of facility policy, the facility failed to implement their abuse policy when an allegation of staff to resident abuse was alleged and not investigated thoroughly. This affected one (#46) of one resident reviewed for abuse The facility census was 70. Findings include: Review of the medical record for Resident #46 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment completed on 08/19/19 revealed the resident was cognitively intact. Review of the SRI (# 1) dated 09/17/19 revealed Resident #46 reported Nursing Aide (NA) #107 had put him to bed and was a little rough. The SRI also alleged the NA turned off the resident's call light without responding to the resident's needs. Review of the facility's investigation revealed on 09/19/19 at 9:15 [NAME]M. Resident #46 reported to the Director of Nursing (DON) #102 that NA #107 had put him to bed and that it was a little rough and was sat down on his privates. Resident #46 also revealed when the NA rolled him over he about rolled out of bed. Resident #46 revealed he did not believe the NA was trying to harm him, however felt the NA was rougher than the other staff. The facility investigation revealed there had been two staff who had reported Resident #46 felt NA #107 man-handled him and was very rough and had shoved him against the wall. There was no evidence the facility investigated the alleged physical abuse. Resident #46 and the resident's roommate were the only residents interviewed. Interview on 10/15/19 at 10:05 [NAME]M. with Resident #46 revealed NA #107 had dropped him on the bed causing him pain. The resident revealed he had reported the incident to the facility. Interview on 10/17/18 at 11:49 [NAME]M. with Administrator #100 and DON #102 confirmed a physical assessment for Resident #46 had not been completed after the alleged incident. DON #102 confirmed no other residents were interviewed regarding the alleged physical abuse other than Resident #46 and his roommate. Review of facility policy, Abuse and Neglect, effective 10/12/99 and last reviewed on 07/18/19, revealed the facility would thoroughly investigate all reports of alleged abuse and neglect. The facility policy revealed when there is an allegation of abuse by a staff member toward a resident the nurse will assess the resident for any injury.

Based on medical record review, review of the facility self reported incident (SRI), resident interview, staff interview, and review of facility policy, the facility failed to investigate an allegation of staff to resident abuse thoroughly. This affected one (#46) of one resident reviewed for abuse The facility census was 70. Findings include: Review of the medical record for Resident #46 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment completed on 08/19/19 revealed the resident was cognitively intact. Review of the SRI (# 1) dated 09/17/19 revealed Resident #46 reported Nursing Aide (NA) #107 had put him to bed and was a little rough. The SRI also alleged the NA turned off the resident's call light without responding to the resident's needs. Review of the facility's investigation revealed on 09/19/19 at 9:15 [NAME]M. Resident #46 reported to the Director of Nursing (DON) #102 that NA #107 had put him to bed and that it was a little rough and was sat down on his privates. Resident #46 also revealed when the NA rolled him over he about rolled out of bed. Resident #46 revealed he did not believe the NA was trying to harm him, however felt the NA was rougher than the other staff. The facility investigation revealed there had been two staff who had reported Resident #46 felt NA #107 man-handled him and was very rough and had shoved him against the wall. There was no evidence the facility investigated the alleged physical abuse. Resident #46 and the resident's roommate were the only residents interviewed. Interview on 10/15/19 at 10:05 [NAME]M. with Resident #46 revealed NA #107 had dropped him on the bed causing him pain. The resident revealed he had reported the incident to the facility. Interview on 10/17/18 at 11:49 [NAME]M. with Administrator #100 and DON #102 confirmed a physical assessment for Resident #46 had not been completed after the alleged incident. DON #102 confirmed no other residents were interviewed regarding the alleged physical abuse other than Resident #46 and his roommate. Review of facility policy, Abuse and Neglect, effective 10/12/99 and last reviewed on 07/18/19, revealed the facility would thoroughly investigate all reports of alleged abuse and neglect. The facility policy revealed when there is an allegation of abuse by a staff member toward a resident the nurse will assess the resident for any injury.

Based on medical record review, observations, staff interviews, review of information from the National Pressure Ulcer Advisory Panel (NPUAP), and review of facility policy, the facility failed to notify the physician of the development of a pressure ulcer, failed to obtain physician orders for a treatment to a pressure ulcer, and failed to properly assess a pressure ulcer. This resulted in actual harm to Resident #56 when a Stage 2 pressure ulcer was observed on the sacrum, the ulcer was not fully assessed, and the physician was not notified for the appropriate treatment until the area was assessed as a Stage 3 pressure ulcer (full-thickness loss of skin which may contain tunneling) seven days later. This affected one (#56) of three residents reviewed for pressure ulcers. The facility identified two residents in the facility with pressure ulcers. The facility census was 70. Findings include: Review of the medical record for Resident #56 revealed an admission 03/12/13. [DIAGNOSES REDACTED]. The resident began receiving hospice services on 09/06/18. Review of the Minimum Data Set (MDS) assessment, dated 08/07/18, revealed Resident #56 had severe cognitive impairment. The assessment indicated the resident was dependent with two assist for bed mobility, bed transfers, and toilet use. The resident required one person assist for personal hygiene, and dressing. Walking did not occur. Resident #54 required extensive assistance with one assist for locomotion on and off the unit. Resident #56 was always incontinent of urine, frequently incontinent of bowel and s not in a toileting program. Resident #56 had a moisture associated skin damage. Review of the care plan, dated 10/17/14, revealed Resident #56 was at risk for skin breakdown due to decreased mobility, decreased range of motion/contracture, [DIAGNOSES REDACTED]. Interventions included assess/record/monitor wound healing, measure the length, width, and depth where possible, and assess and document the status of wound perimeter, wound bed and healing progress. Review of a physician order dated 07/02/18 revealed treatment orders for moisture associated skin damage on the left sacrum and right sacrum. The ordered treatment was cleanse area with normal saline, apply bordered foam dressing, change every three days and as needed. The order also read to monitor the wound on the right sacrum daily for pain and the status of the surrounding tissue. The medical record had no documentation of the appearance or any ongoing monitoring of these areas. Review of a Skin Grid Other Skin Condition form, dated 07/02/18, revealed Resident #56 had an area of impaired skin on the sacrum which measured 1.8 centimeters (cm) by 1.5 cm by 0.3 cm deep and identified as moisture related. The assessment has no description of the area of impairments. The skin grid other skin condition form, dated 08/25/18, continued to identify an area of moisture related impairment to the resident's sacrum. The area was identified to be 2.5 cm long by 1.3 cm wide by 0.3 cm deep. There was no assessment of the appearance of this are of impairment. Review of the Skin Grid Pressure form revealed on 09/06/18 a Stage 2 pressure ulcer was identified on Resident #56's sacrum. There were no measurements of the area. Review of the nursing progress note dated 09/06/18 at 2:45 P.M. revealed the hospice nurse assessed the skin of the resident's sacrum and assessed the area to be a Stage 2 ulcer. Review of the medical record revealed no evidence the physician and family were notified of this new area. Review of the treatment administration record (TAR) for (MONTH) (YEAR) revealed the facility continued the treatment to the open area to the sacrum of cleansing the area with normal saline, applying bordered foam dressing, change dressing every three days and as needed. The treatment was rewritten as a new entry in the TAR on 09/07/18, however no new physician order had been written. Review of the plan of care revealed a revision on 09/07/18 to identify Resident #56 had a Stage 2 pressure ulcer to the sacrum. Interventions added 09/07/18 included report improvements and declines to the physician. Review of the Skin Grid Pressure form, dated 09/10/18, revealed the open area on the sacrum was documented to be a Stage 2 pressure ulcer. The area measured 2 cm long by 2 cm wide by 0.2 cm deep with an area of tunneling which was 1.5 cm in size. There was serous drainage and pain was present. The assessment indicated no change in treatment. The record contains no documentation the physician or family were notified of the worsening pressure ulcer. Review of the Skin Grid Pressure form, dated 09/11/18, revealed the pressure ulcer had increased in size, was now a Stage 3, and measured 3 cm long by 3.5 cm wide by 1.5 cm deep. The area was identified to have 1.0 cm tunneling with a line drawn through the entry. The area of the grid which identified the location of tunneling had a line drawn through it from 2:00 to 7:00. The entry revealed under treatment to continue treatment. There was no documentation the family or physician were notified the pressure ulcer increasing in stage or size. Observation on 09/11/18 at 3:56 P.M. of a dressing change to Resident #56's sacrum, performed by Licensed Practical Nurse (LPN) #310, revealed upon removal of the old dressing, a light pink drainage was noted. LPN #310 measured the wound to be 3 cm long by 3 cm wide by 1.5 cm deep. The wound bed and edges were observed to be pink and there appeared to be an area of tunneling to the right of the sacrum. Interview on 09/12/18 at 9:28 A.M., the Assistant Director of Nursing (ADON) verified the physician had not been notified of the development of pressure ulcer for Resident #56 or of the worsening of the sacral pressure ulcer. Interview on 09/13/18 11:02 A.M., the ADON revealed the Certified Nurse Practitioner (CNP) had just assessed Resident #56's pressure ulcer. The ADON verified the CNP staged the pressure ulcer as a Stage 3 and was contacting the physician to see what treatment plan he wanted to provide. Review of the physician order, written by the CNP and dated 09/13/18, revealed a new treatment was ordered for the Stage 3 pressure ulcer. The treatment was to cleanse the open area to the sacrum with normal saline, apply gauze dampened with Dakin's solution 5%, and cover with [MEDICATION NAME] dressing, change daily and as needed if soiled or dislodged. Hospice to change the dressing every Monday and Thursday. Interview on 09/13/18 at 12:25 P.M., the Director of Nursing (DON) verified the physician was not notified of the presence of the pressure ulcer to the sacrum until after the wound was identified to be a Stage 3. The DON verified there was no physician order for [REDACTED]. Review of the facility policy titled Pressure Ulcers, revised 03/08/18, revealed the current National Pressure Ulcer Advisory Panel definitions of staging for pressure ulcers will be adopted by the facility. The nurse manager or designee will assist with wound rounds and evaluate appropriate treatment, implementation and coordination of care. The treatment will include as follows; Treatment will be chosen based on status of the wound and individualized to each resident. Weekly wound management and the nurse will notify the physician of signs of wound deterioration. The facility may consult wound care if unable to maintain appropriate treatment at the facility. The facility will monitor the wound daily for pain and status of surrounding tissue. Review of information from the NPUAP revealed a Stage 3 Pressure Injury is full-thickness skin loss in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed.

Based on review of medical records, review of hospital records, interviews with facility staff, interview with the attending physician, review of laboratory results, review of the facility policy on monitoring medications, and the Nursing Drug Handbook, 36th Edition, the facility failed to ensure a resident on oral anticoagulant therapy ([MEDICATION NAME]), with a history of elevated International Normalized Ratio (INR), who was having signs and symptoms of [MEDICATION NAME] toxicity was monitored. The failure to monitor the anticoagulant therapy resulted in Immediate Jeopardy and actual harm to Resident #51 when the resident required transportation to the local emergency room with [MEDICAL CONDITION] evidenced by mahogany colored stools and mahogany colored emesis, and an INR level (used to monitor therapeutic levels of blood clotting) identified as too high to count. As a result of the [MEDICAL CONDITION], Resident #51 expired at the facility on [DATE]. This affected one (#51) of eight residents reviewed who received anticoagulant (blood thinning) medication. The facility census was 71. On [DATE] at 3:51 P.M., the Administrator, Administrator in Training (AIT), and Director of Nursing (DON), were notified Immediate Jeopardy began on [DATE] when the facility failed to timely notify the physician Resident #51 was having signs and symptoms of possible [MEDICATION NAME] toxicity. The resident continued to receive [MEDICATION NAME] 2.5 milligrams (mg) until the resident was sent out to the emergency room (ER) on [DATE] at 9:00 A.M. after exhibiting signs and symptoms of bleeding for ten hours. On [DATE] at 10:00 P.M. Resident #51 was noted to have a moderate amount of dark brown-red stool, the resident was passing dark brown-red clots with the stool, her color was pale, and the resident complained of not feeling well. The physician was not notified of the resident's condition until the morning of [DATE] when the physician assessed the resident on rounds at 8:00 A.M. The resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. The resident subsequently received aggressive intravenous (IV) fluid support for shock, fresh frozen plasma (FFP), Vitamin K, and an IV proton pump inhibitor in an attempt to reverse the effects of the blood thinning medication [MEDICATION NAME]. The resident returned to the facility on [DATE] at 2:50 P.M and expired in the facility at 3:06 A.M. on [DATE]. The Immediate Jeopardy was removed on [DATE] when all the medical records of the remaining eight residents receiving anticoagulant medications revealed the residents had INR levels within acceptable therapeutic ranges, were receiving appropriate laboratory monitoring, and no signs and symptoms of bleeding were noted. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan to ensure on-going compliance and the facility implemented the following corrective actions: · On [DATE] at 9:00 A.M., Resident #51 was sent to the ER for evaluation and treatment. · On [DATE], review of the medical records of eight current residents (#8, #12, #37, #42, #45, #66, #74, and #84) receiving [MEDICATION NAME] confirmed the residents were receiving the accurate dosage of medication, they had [MEDICATION NAME] (PT)/INR monitoring in place with levels identified within therapeutic parameters, and there were no documented ¿signs or symptoms of bleeding. On [DATE], Resident #37 was identified to be the last resident receiving [MEDICATION NAME] to have a PT/INR obtained, which was found to be of a therapeutic level, and no documented signs or symptoms of bleeding were noted in the medical record. · On [DATE] and [DATE], the DON and Registered Nurse (RN) #85 audited the medical records of all current residents receiving [MEDICATION NAME] to ensure each resident had current orders for INR levels, the INR levels were obtained as ordered, there was a care plan in place addressing the use of [MEDICATION NAME], and all [MEDICATION NAME] flow sheets were up to date. · On [DATE], the Nurse Managers began audits of the medical records of any resident on [MEDICATION NAME] to ensure monitoring of the laboratory work was completed and documentation was evidenced for any signs and symptoms of bleeding. These audits will be done weekly for three months, then biweekly for two months, then monthly for a year. At the end of the year, the monitoring will be re-evaluated to determine if audits are to continue. · On [DATE], the Nurse Managers began random audits of the nursing notes for residents who have a change in condition to ensure the physician has been notified. These audits will be done weekly for three months, then biweekly for two months, then monthly for a year. At the end of the year, the monitoring will be re-evaluated to determine if audits are to continue. · On [DATE], the facility revised the policy titled [MEDICATION NAME] to include the monitoring of signs and symptoms of bleeding, the monitoring of laboratory tests, to notify the physician of any abnormal findings, and to notify the physician of all laboratory tests. · On [DATE], the facility revised the policy titled Notification of Physician to indicate the facility will contact the physician or the on-call clinician in the event of a significant change in a resident's condition, or the need to alter a resident's treatment. · On [DATE], all nurses were educated by the AIT and the DON regarding the administration of anti-coagulant therapy ([MEDICATION NAME]) which included factors that affect [MEDICATION NAME] therapy, side effects of [MEDICATION NAME], when to notify the physician, and documentation of monitoring effects of [MEDICATION NAME]. The nurses were also educated on the facility's new policy regarding physician notification. · On [DATE], a Quality Assurance Committee meeting was held to initiate a performance improvement plan regarding Quality of Care and Treatment: Notification of Physician, [MEDICATION NAME] Therapy, and Care Planning. The Medical Director attended this meeting. · On [DATE], the Registered Nurse Educator began educating State tested Nurse Aides (STNA) regarding observation of residents and reporting to the nurse. · On [DATE] between 8:20 A.M. and 11:45 A.M., Licensed Practical Nurse (LPN) #97, State tested Nurse Aides #106 and #114, and RN #85 were interviewed regarding the in-service they received addressing signs and symptoms of bleeding, documentation of assessment of signs and symptoms of bleeding to be completed each shift, notification of abnormal laboratory results, and the need to immediately contact the physician. All staff interviewed were able to correctly articulate the information provided during the in-service. Findings include: Review of the medical record revealed Resident #51 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of physician's orders upon admission revealed Resident #51 had an order for [REDACTED]. The physician orders dated [DATE] included the antibiotic [MEDICATION NAME] 400 mg daily for five days, which was noted to be administered as ordered. A review of the current plan of care did not contain a care plan for the monitoring of the anti-coagulant medication, [MEDICATION NAME]. Review of laboratory reports dated [DATE] revealed the PT/INR level was noted to have an elevated INR level of 9.1 (average normal range is 2.0 - 3.0). The physician was notified and an order was received to hold Resident #51's [MEDICATION NAME] for three days, then repeat the PT/INR. Review of the laboratory report dated [DATE] revealed the INR was normal at 3. The physician was notified of Resident #51's INR level and ordered the [MEDICATION NAME] to be resumed at 2.5 mg daily and to repeat the PT/INR in two weeks ([DATE]). Review of the nurse's progress notes completed by LPN #91 on [DATE] at 7:30 P.M., revealed Resident #51 was noted to be lethargic, but easily woke when the nurse touched the resident's shoulder and called the resident's name. LPN #91 noted the resident's color to be pale gray and the resident complained of weakness. The resident's vital signs were noted to be within normal limits (WNL), with a blood pressure (BP) of ,[DATE] millimeters of mercury (mm/Hg), pulse of 94 beats per minute (bpm), respirations of 14 per minute, and a temperature of 97 degrees Fahrenheit (F). LPN #91 noted the resident's skin to be cool to the touch. The documentation revealed there was no [MEDICAL CONDITION] or discoloration to the bilateral lower extremities. Review of the nurse's progress notes dated [DATE] at 1:00 A.M. noted Resident #51 was alert and oriented, very weak and pale. The nurse documented the resident voiced no complaints. A nurse's progress note dated [DATE] at 1:00 A.M. again noted the resident to be pale and weak. Review of the nurse's progress note dated [DATE] at 10:00 P.M. revealed Resident #51 had dark brown stool with a moderate amount of dark brown-red drainage and dark brown-red clots. The resident's bowel sounds were noted as active and the resident complained of not feeling well. The resident was noted to be pale, warm and dry. Her BP was ,[DATE] mm/Hg and her pulse was 94 bpm. The note documented the resident stated Just let me sleep so I feel better. There was no evidence in the record of the physician being notified of the resident's change in condition. The nurse's progress note on [DATE] at 2:30 A.M. revealed the resident had no further brown-red stools. Review of the nurse's progress notes dated [DATE] at 6:00 A.M. documented Resident #51 was having mahogany colored loose stools with no complaints of discomfort. The note documented the physician was to assess the resident on his morning rounds. There was no evidence the physician was contacted regarding the resident's condition at 6:00 A.M. Review of the nurse's progress note dated [DATE] at 8:00 A.M. documented Resident #51 was very weak, pale, and unable to keep her eyes open. The resident had an extra-large, soft, mahogany colored stool with red drainage present. The resident also complained of nausea, and was coughing with mahogany colored sputum noted. The resident's BP was ,[DATE] mm/Hg and her apical pulse was 104 bpm. Her temperature was 101.2 degrees F. The nurse's progress note dated [DATE] at 8:20 A.M. documented the physician was in to assess the resident, and after a phone call to the resident's family, the resident was transported to the hospital at 9:00 A.M. Review of the physician's progress note dated [DATE] revealed Resident #51 had been doing well, however over the past 24 hours she had mahogany colored stool and at least one mahogany colored emesis. Documentation reflected she had an elevated temperature of 101 degrees F, her blood pressure was relatively low at ,[DATE] mm/Hg, and her pulse was 104 bpm. The physician documented the resident stated she felt weak and nauseated. The physician noted the resident looked very pale and her cheeks were noted to be sunken. The physician documented the resident was really dehydrated, and the resident's heart rate and rhythm were observed to be [MEDICAL CONDITION] (elevated heart rate) and her last blood count showed a hemoglobin was low at 7.8 gm/dL. Review of the hospital History and Physical (H&P), dated [DATE], revealed Resident #51 was sent to the emergency room (ER) after mahogany colored hemoptysis (blood colored sputum) and a mahogany colored, melenic stool (stool containing blood). The report documented while in the ER the resident rapidly deteriorated, became sleepy, stuporous, and almost obtunded. The resident had a hemoglobin of around 7.8 gm/dL with continued upper [MEDICAL CONDITION] noted. The H&P noted the medication list from the nursing facility suggested the resident was anticoagulated with [MEDICATION NAME]. An immediate PT/INR was drawn, with the results reported as too high to count. The report documented the laboratory could not report the PT/INR results as the laboratory indicated it was exceptionally high. The resident had blood encrusted around her nares, rectum, and oropharynx, with dry lips noted. The resident was in hypovolemic shock, had severe upper [MEDICAL CONDITION] with hematemesis (blood in emesis) and melenic stools. Documentation reflected her condition appeared to be caused from her [MEDICATION NAME], which was identified as supra-therapeutic, perhaps from the continued dosing, or perhaps from an antibiotic drug to drug interaction. In addition, the H&P noted the physician had discussed Resident #51's condition with the resident's daughter to confirm the reason for the [MEDICATION NAME] use. The report indicated an old record indicated Resident #51 was prescribed [MEDICATION NAME] for a history of [MEDICAL CONDITION], which her daughter could not confirm. The report noted the physician's plan was to reverse the effects of the [MEDICATION NAME] with the use of Vitamin K and fresh frozen plasma. The resident's prognosis was documented as guarded. Review of the nurse's progress notes dated [DATE] at 2:50 P.M. revealed Resident #51 was readmitted to the nursing facility. The admission [DIAGNOSES REDACTED].#51 was no longer receiving [MEDICATION NAME]. The nurse's progress note identified the resident to be very weak and lethargic with a BP of ,[DATE] mm/Hg, a pulse of 106 bpm, and a temperature of 97.5 degrees F. Review of the nurse's progress notes dated [DATE] at 3:06 A.M. revealed the resident had expired. Review of the discharge summary, signed by the physician on [DATE], revealed the resident's discharge [DIAGNOSES REDACTED]. Interview on [DATE] at 2:30 P.M. with the DON verified based on the resident's history, she would have expected the nursing staff to call and notify the physician when the resident began having evidence of bleeding. During an interview on [DATE] at 3:04 P.M., LPN #91, who documented the nurse's progress note on [DATE], stated it was the first time she had cared for Resident #51 during her stay at the facility. She stated the resident was alert for the most part and her vital signs were stable. She stated the resident was monitored throughout the shift and confirmed she had not notified the physician regarding the resident's condition. Interview on [DATE] at 8:20 A.M., LPN #92, who documented the nurse's progress note dated [DATE], stated she worked from 7:00 P.M. to 3:00 A.M. She stated the resident had a respiratory infection and it was the first time the resident exhibited discolored stools. LPN #92 verified she was aware Resident #51 was on [MEDICATION NAME], but she did not feel the resident was having signs of bleeding related to the [MEDICATION NAME], but thought the discolored stools were from hemorrhoids. LPN #92 stated she was not aware Resident #51 recently had and elevated INR, if she were she may have acted differently. She verified she chose to monitor the resident. Interview on [DATE] at 9:40 A.M., the resident's physician confirmed the facility should have notified him when the resident began displaying the symptoms of being pale and hypotensive. Review of the facility policy titled Medication Monitoring: Standing Orders for Routine Medication Therapy Monitoring, revised [DATE], revealed the facility established monitoring standards for certain medications to promote safe and effective use of the medications. The standing orders for [MEDICATION NAME] (generic [MEDICATION NAME]) were to obtain a monthly serum [MEDICATION NAME] time and INR, unless physician ordered differently. The standing orders indicated dosage adjustments may indicate the need for more frequent testing until stabilized. Review of the Nursing Drug Handbook, 36th edition, identifies [MEDICATION NAME] as an anticoagulant and used as treatment of [REDACTED]. The medication should be used with caution and the most serious risk of therapy is hemorrhage. The dosage is adjusted according to the INR results and the elderly tend to require lower dosages to produce a therapeutic level of anticoagulation. Under black box warning it indicates to regularly inspect patient for bleeding gums, bruises on arms or legs, nosebleeds, melena (dark and sticky stools), tarry stool, hematuria and hematemesis.