Every finding on record at Willows Health and Rehab CTR

Based on closed medical record review and staff interview, the facility failed to timely identify and implement interventions to prevent significant/severe weight loss. Actual Harm occurred when Resident #173 was assessed to have a severe 24.8 pound/13.3 percent (%) weight loss in 30 days without evidence of timely identification of the resident's decreased oral intake or timely intervention to address the cause of the weight loss. On 01/17/24 Resident #173 complained of tooth pain and was discovered to have a loose front tooth. The resident complained of continued pain with a decrease in oral intake. On 01/18/24 Resident #173 weighed 186.2 pounds and the next weight obtained on 02/13/24 was 161.4 pounds which reflected a 24.8 pound (severe)/13.3 % weight loss in under 30 days. This affected one resident (#173) of four residents reviewed for nutrition. The facility census was 65 residents. Findings include: Review of the closed medical record for Resident #173 revealed an admitted [DATE] and a discharge date of [DATE] with diagnoses that included Alzheimer's disease, dementia, obesity, chronic respiratory failure, hypertension, osteoarthritis, gastrostomy tube (g-tube), and anxiety disorder. Review of the care plan for Resident #173 dated 05/18/21 revealed the resident was at nutritional and hydration risk related to malnutrition, mechanically altered diet, dysphagia, and history of gastrostomy tube. Interventions included the following: monitor dietary intake and/or hydration, monitor labs, and monitor weights, monitor need for increased nutritional intervention related to diagnosis, medications and listed problems. Review of physician's orders for Resident #173 dated 01/24/23 revealed an order for regular diet, pureed texture, thin consistency. Review of the nutrition progress note for Resident #173 dated 04/07/23 revealed the resident had progressed with her oral meal intake and her enteral nutrition was discontinued. The gastrostomy tube was flushed with water to maintain patency. Review of the dietary assessment for Resident #173 dated 11/08/23 revealed the resident received a regular diet, pureed texture, thin consistency liquids and consumed approximately 76 to 100 % of meals. The resident's most recent weight on 10/09/23 was 185.6 pounds. Review of the nurse progress note for Resident #173 dated 01/17/24 revealed the facility staff contacted Certified Nurse Practitioner (CNP) #650 because the resident had a loose front tooth which appeared to cause the resident some discomfort. Review of the weight records for the facility revealed Resident #173 weighed 186.2 pounds on 01/18/24. Review of the progress note for Resident #173 dated 01/17/24 per CNP #650 revealed the CNP examined the resident due to reports from nursing that the resident had a sore tooth and was refusing food and drinks. Further review of the note revealed the resident had a loose tooth noted to the lower front jaw and the CNP gave orders for mouth care every shift and to make an appointment with the dentist for loose tooth. Review of the nursing progress note for Resident #173 dated 01/17/24 revealed the CNP also gave an order for Orajel mouth gel to gum line before meals and snacks. Review of the Medication Administration Record (MAR) for Resident #173 from 01/17/24 to 02/17/24 revealed documentation that Orajel was administered to resident's gum line before meals and snacks for pain as ordered. Review of the weight records for the facility revealed Resident #173 weighed 186.2 pounds on 01/18/24. Review of progress note for Resident #173 per NP #850 dated 01/19/24 revealed the facility staff reported resident had a front lower teeth that was loose. NP #850 attempted to examine the resident, but the resident refused to open her mouth. Review of the progress note for Resident #173 dated 01/19/24 revealed the facility called the dentist for an appointment for the resident and was awaiting a call back. Review of the progress note for Resident #173 dated 01/21/24 at 7:37 P.M. revealed the resident ate 50% of meals served on this date. Review of the progress note for Resident #173 dated 01/22/24 timed at 7:19 P.M. revealed the resident ate 50% of her meal. Review of the progress note for Resident #173 dated 01/25/24 timed at 7:20 P.M. the resident ate 50% of meals served on this date. Review of the physician's orders for Resident #173 revealed and order dated 01/22/24 revealed an order for a dental exam and x-ray on 02/20/24 at 10:00 A.M. Review of the progress note for Resident #173 dated 01/30/24 at 6:56 P.M. revealed the resident ate 50% of the lunch meal. Review of the progress note for Resident #173 dated 01/31/24 timed at 6:52 P.M. revealed the resident ate 50% of meals served. Review of the medication administration note for Resident #173 dated 02/01/24 timed at 3:26 P.M. revealed the resident was given two Tylenol tablets for mouth pain. Review of the progress note dated 02/02/24 at timed at 7:02 P.M. revealed the resident at 25% of meals served. Review of the progress note for Resident #173 dated 02/05/24 revealed the facility set up a same-day emergency dental appointment for resident on 02/05/24. Review of the progress note for Resident #173 dated 02/05/24 revealed the dentist would call to schedule the resident for oral surgery to remove the loose front tooth. Review of the progress note for Resident #173 dated 02/06/24 timed at 5:48 P.M. revealed the resident refused the breakfast meal and ate 25% of the lunch and dinner meals. Review of the progress note for Resident #173 dated 02/07/24 timed at 8:08 P.M. revealed the resident at 50% of the meal. Review of the progress note for Resident #173 dated 02/11/24 timed at 5:57 P.M. revealed the resident ate 50% of her meals. Review of the Minimum Data Set (MDS) assessment for Resident #173 dated 02/10/24 revealed the resident was cognitively impaired and was able to feed herself with set-up assistance and was dependent on staff for all other activities of daily living (ADLs.) Review of the weight records for the facility revealed Resident #173 weighed 161.4 pounds on 02/13/24. The facility reweighed the resident and confirmed the resident's weight was 161.4 pounds. Review of the physician orders for Resident #173 revealed an order dated 02/13/24 for Boost supplement three times a day due to weight loss. Review of the progress note for Resident #173 dated 02/18/24 timed at 4:20 P.M. revealed the resident had difficulty breathing, had a low blood pressure of 75/33 and a low oxygen saturation level of 85 %. Resident #173 was sent to the hospital due to a change in condition and was admitted . The resident did not return to the facility following the hospitalization . Interview on 05/14/24 at 10:14 A.M. with Registered Dietitian (RD) #912 revealed Resident #173 was admitted to the facility in May of 2021 and received all nutrition via g-tube at that time. RD #912 confirmed the resident's diet was upgraded to oral meals in April of 2023, but the resident still had a g-tube in place and the facility maintained the patency of the tube with regular water flushes. RD #912 further confirmed Resident #173 had a significant (severe by Centers for Medicare/Medicaid (CMS) definition -weight loss of greater than five percent in one month) weight loss of 24.8 pounds, a weight loss of 13.3% from 01/18/24 to 02/13/24. RD #912 confirmed she recommended a Boost supplement for Resident #173 three times per day but not until on 02/13/24. RD #912 confirmed the facility identified Resident #173 had a loose and sore tooth on 01/17/24 and did not obtain additional weights for Resident #173 from 01/18/24 to 02/13/24 nor did the facility implement any additional nutritional interventions during this time frame. Interview on 05/15/24 at 2:47 P.M. with Regional Nurse (RN) #750, the Interim Director of Nursing (DON), and Licensed Practical Nurse (LPN) #901 confirmed Resident #173 complained of mouth pain in mid-January 2024 and on 01/17/24 staff confirmed resident had a loose tooth which caused the resident pain. RN #750 revealed the facility did schedule an emergency dental appointment and extraction for Resident #173. LPN #901 confirmed staff began to provide a Boost supplement to Resident #173 starting on 02/13/24 due to resident's weight loss. Further interview with RN #750 and the Interim DON confirmed Resident #173 had a significant weight loss of 24.8 pound, 13.3% from 01/18/24 to 02/13/24. Interview confirmed the facility did not obtain any weights during this time frame for the resident nor did the facility initiate interventions to prevent weight loss until 02/13/24.

Based on record review, staff interview, and review of the facility policy the facility failed to develop comprehensive care plans for residents who were smokers. This affected four (Residents #2, #17, #64, #65) of twenty-one residents reviewed for care plans. The facility census was 65 residents. Findings include: Review of a document provided by the facility dated 05/01/24 revealed there were 21 residents who were smokers. Residents #2, #17, #64, #65 were listed as smokers. Review of the medical record for Resident #2 revealed an admitted [DATE] with diagnoses including type two diabetes, hypertension, and atrial fibrillation. Review of the care plan for Resident #2 dated 04/04/24 revealed it did not include a care plan for smoking. Review of the medical record for Resident #17 revealed an admitted [DATE] with diagnoses including type two diabetes, hypertension, and bipolar disorder. Review of the care plan for Resident #17 dated 03/14/24 revealed it did not include a care plan for smoking. Review of the medical record for Resident #64 revealed an admitted [DATE] with diagnoses including schizophrenia, hypertension, and depression. Review of the care plan for Resident #64 dated 03/10/24 revealed it did not include a care plan for smoking. Review of the medical record for Resident #65 revealed an admitted [DATE] with diagnoses including malignant neoplasm of larynx, squamous cell carcinoma, and chronic obstructive pulmonary disease (COPD). Review of the care plan for Resident #65 initiated 03/10/24 revealed it did not include a care plan for smoking. Interview on 05/16/24 at 11:05 A.M. with Regional Registered Nurse (RRN) #750 confirmed Residents #2, #17, #64, and #65 were smokers, but they did not have care plans for smoking. Review of the facility policy titled Comprehensive Care Planning revised 03/02/21 revealed the facility would establish a care plan for every resident that included the resident's medical, nursing, mental, and psychosocial needs.

Based on medical record review, staff interview, family interview, and review of the facility policy, the facility failed to ensure resident care plans with updated with changes in code status. This affected one (Resident #50) of 29 residents reviewed for care plans. The facility census was 65 residents. Findings include: Review of the medical record for Resident #50 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure, vascular dementia without behavioral disturbance, chronic kidney disease, cardiomegaly, and diabetes. Review of May 2024 physician's orders for Resident #50 revealed an order dated 02/04/24 for the resident be a full code (all resuscitative interventions would be performed in the event the resident's heart stopped). There was an order dated 02/20/24 for Resident #50 to be admitted to hospice care for a diagnosis of COPD. The resident remained a full code. Review of the care plan for Resident #50 dated 02/14/24 revealed the resident's code status was do not resuscitate comfort care arrest (DNR-CCA.) Interview on 05/16/24 at 9:52 A.M. with Resident #50's representative and medical decision-maker confirmed the resident was receiving hospice services but the resident was to remain a full code, meaning in the event that Resident #50's heart stopped he wanted everything possible to be done to maintain life. Interview on 05/16/24 at 11:05 A.M with Regional Nurse (RN) #750 confirmed Resident #50 was a full code, but the resident's care plan had not been updated with the correct code status. Review of the facility policy titled Comprehensive Care Planning dated 03/02/21 revealed the Minimum Data Set (MDS) Coordinator was responsible for reviewing and updating the plan of care as needed. The MDS Coordinator was to review the facility's 24-hour report daily for any changes in the resident's condition and update the care plan accordingly.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure accurate pre-dialysis communication was provided to the dialysis center, failed to ensure the dialysis provider provided the facility with timely post-dialysis information, and failed to respond to concerns from the dialysis center. This affected one (Resident #36) of one resident reviewed for dialysis. The facility census was 65 residents. Findings include: Review of the medical record for Resident #36 revealed an admitted [DATE] with diagnoses including end stage renal disease, dependence on dialysis, diabetes, peripheral vascular disease, bilateral below the knee amputation, schizoaffective disorder, and noncompliance with renal dialysis. Review of the physician's orders for Resident #36 revealed an order for the resident to receive hemodialysis outside the facility on Mondays, Wednesdays, and Fridays. The facility was to send a bagged meal/snack with Resident #36 to dialysis. A dialysis communication tool was to be completed and sent to dialysis with the resident. A skin check was to be completed upon return from dialysis. Resident #36 was not on a fluid restriction and was to receive a renal diet with double protein portions. Review of the pre-dialysis communication tools from February 2024 through May 2024 from the facility to the dialysis center for Resident #36 revealed the facility completed the tool and sent it to the dialysis provider for each visit, but the facility did not complete the dialysis tool accurately. Resident #36 was marked as being on a fluid restriction and that the resident was not to have bagged meal/snack sent with him on the following dates: 02/02/24, 02/12/24, 03/08/24, 03/15/24, 04/07/24, 04/19/24, 04/22/24, 04/24/24, 04/26/24, 04/29/24, 05/10/24, and 05/13/24. Review of the post-dialysis communication tool for Resident #36 from the dialysis center to the facility revealed the dialysis provider was to send back information regarding how much fluid was removed from the resident, the post-dialysis weight, how the resident tolerated the session. No information was provided to the facility upon treatment completion for Resident #36 on the following dates: 04/19/24, 04//22/24, 04/29/24, 05/10/24. Review of the progress notes for Resident #36 dated 04/19/24 to 05/21/24 revealed they did not include documentation of the facility contacting the dialysis provider for treatment information for the following dates: 04/19/24, 04//22/24, 04/29/24, or 05/10/24. Review of the dialysis communication tool returned by the dialysis provider to the facility dated 03/15/24 for Resident #36 revealed the dialysis provider noted the resident was complaining of pain to his buttocks and that the facility staff had not been treating the resident's bottom. Review of the progress notes for Resident #36 dated 03/15/24 to 05/21/24 revealed they did not include documentation that the facility was aware of the dialysis provider's concerns or that the facility followed up with the dialysis provider. Review of the dialysis communication tool returned by the dialysis provider to the facility dated 04/26/24 revealed the resident was complaining of pain in his genitals and was having discharge from it and that this was an ongoing problem, and nothing was being done. Review of the progress notes for Resident #36 dated 04/26/24 to 05/21/24 revealed they did not include documentation that the facility was aware of the dialysis provider's concerns or that the facility followed up with the dialysis provider. Interview on 05/21/24 at 3:30 P.M. with Regional Registered Nurse (RRN) #750 confirmed the pre-dialysis tool sent to the dialysis provider for Resident #36 was not consistently completed with accuracy regarding the resident's fluid status and diet interventions. RNN #750 further confirmed the facility should have followed up with the dialysis provider for the dates in which the facility did not receive post-dialysis documentation. RNN #750 confirmed the facility did not follow up with the dialysis provider regarding the concerns noted on the post-dialysis communication forms dated 03/15/24 and 04/26/24. Review of the facility policy titled Hemodialysis Care Policy last revised 08/24/23, revealed the facility was to include the following information in the dialysis communication tool shared with the dialysis provider: vital signs, pre-treatment weight unless performed at dialysis, any medication administered before treatment, time of last meal, fluid intake, any additional alerts or information. The tool was to go with the resident to treatment. The post-dialysis process was to receive report from the dialysis provider and/or review the dialysis communication tool documentation completed by the dialysis provider. Information post-dialysis will include the following: vital signs, post-treatment weight, any lab draws and/or results, any medications administered during or after treatment, any new orders, any alerts or information, monitoring the dialysis site for bleeding, monitor for dizziness, any meal/and or fluids consumed at dialysis.

Based on observation, interview and record review, the facility failed to ensure Resident #121's pain was managed effectively. Resident #121 sustained actual harm as evidenced by severe pain and depression when physician ordered [MEDICATION(S)] patches for pain associated with [CONDITION(S)] was not provided for eighteen days. This affected one of two residents (Residents #121 and #63) reviewed for pain management. The facility census was 71. Findings include: Review of the Resident #121's medical record revealed an admitted [DATE]. Admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admitting physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #121's Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #121 was alert and oriented to time, person and place, and required extensive assistance of one person for bed mobility, transfers, dressing, toileting and personal hygiene. Review of the nursing progress notes dated 04/26/22 at 4:30 P.M. revealed the nurse called the pharmacy and spoke with Representative #1. The note further indicated Resident #121's [MEDICATION(S)] patch was to be billed to the facility until billing to insurance was resolved. In addition, there were 24 pills remaining on the [MEDICATION(S)] script and the [MEDICATION(S)] would be drop shipped to the facility. Review of Resident #121's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #121 on 05/03/22 at 12:08 A.M. Interview with Resident #121 on 05/03/22 at 9:40 A.M. revealed she had been having bad pain since her admission to the facility. At the time of the interview Resident #121 rated her pain a 10 on a scale of 0-10 (zero means no pain, one to three means mild pain, four to seven is considered moderate pain, and eight and above is considered severe pain). Resident #121 was sitting at the side of her bed rocking back and forth. When asked if she informed the nurse, Resident #121 started crying and said telling the nurse did not do any good because they told her they were waiting on the pharmacy. Resident #121 said she finally received her [MEDICATION(S)] patch that was ordered upon admission early that morning, probably about 1:30 A.M. but it took a while for the [MEDICATION(S)] to work like it was supposed to since she had been without the medication for a while. Resident #121 said her depression was getting worse because of the pain. Interview with Licensed Practical Nurse (LPN) #288 on 05/03/22 at 10:00 A.M. revealed she administered Resident #121's medications and Resident #121 never mentioned anything about being in severe pain. LPN #288 said she would assess Resident #121. Interview with Resident #121 on 05/04/22 at 8:40 A.M. revealed Resident #121's current pain level was a five. When asked if Resident #121 informed the nurses of her pain when she was first admitted Resident #121 said she did and they offered her [MEDICATION(S)]. Resident #121 said she took the [MEDICATION(S)] which took the edge off of the pain but never gave her relief like the [MEDICATION(S)] did. Resident #121 said she had pain ranging from seven to 10 when she was not wearing the [MEDICATION(S)] patch. Interview with the Director of Nursing (DON) on 05/04/22 at 10:30 A.M. revealed the nurse who placed the order for the [MEDICATION(S)] patch with the pharmacy did not pass on that Resident #121's insurance would not cover the [MEDICATION(S)] patch. The DON stated the procedure for this kind of situation included notifying the DON immediately because she would call the pharmacy and approve the [MEDICATION(S)] patch order to be shipped and billed to the facility until the insurance coverage problem was corrected. The DON said The Certified Nurse Practitioner (CNP) had ordered Resident #121 [MEDICATION(S)] as needed for pain as part of her admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with CNP #40 on 05/06/22 at 11:00 A.M. revealed she was aware of the problem regarding Resident #121's [MEDICATION(S)] patch. CNP #40 explained Resident #121 was started on the [MEDICATION(S)] at the hospital but due to Resident #121's insurance the medication had not been provided to the facility by the pharmacy. CNP #40 wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked about the effectiveness of [MEDICATION(S)] verses [MEDICATION(S)] for the relief of Resident #121's pain related to [CONDITION(S)], CNP #40 said the [MEDICATION(S)] was not as effective as the [MEDICATION(S)] in relieving Resident #121's pain. During a follow up interview with Resident #121 on 05/06/22 at 12:45 P.M., Resident #121 reiterated she was in a lot of pain prior to getting the [MEDICATION(S)] patch on 05/03/22 and she started to cry again. When asked if she took the [MEDICATION(S)] as often as she could have it, she stated she was not sure because she was unaware the [MEDICATION(S)] was not scheduled to be given at regular intervals and in order to receive the [MEDICATION(S)] she had to ask for the medication. Resident #121 said when she told the nurses she was in pain some of the nurses administered the [MEDICATION(S)]. Interview on 05/06/22 at 1:15 P. M with State tested Nursing Assistant (STNA) #278, regarding whether Resident #121 complained of being in a lot of pain daily, revealed of course she does, she has [CONDITION(S)]. STNA #278 said when any resident complained of pain he immediately reported to the nurse. Interview on 05/06/22 at 1:20 P.M. with LPN #288 revealed Resident #121 complained of pain off and on and when she did, LPN #288 gave her [MEDICATION(S)]. When LPN #288 asked Resident #121 if the [MEDICATION(S)] was effective Resident #121 stated it was for the moment. Interview on 05/06/22 at 1:40 P.M. with STNA #256 revealed STNA #256 had taken care of Resident #121 a few times. STNA #256 indicated Resident #121 did complain about being in pain once when she was first admitted and STNA #256 reported the complaint of pain to the nurse; however, STNA #256 could not remember which nurse.

Based on observation and interview the facility failed to store frozen foods under sanitary conditions. This had the potential to affect all 68 residents receiving food from the facility. There were three resident who were not receiving food from the facility (#45, #52, and #66). The facility census was 71. Findings include: On 05/02/22 from 9:48 A.M. to 10:06 A.M. a tour of the kitchen was conducted with Certified Dietary Manager (CDM) #284. During the tour one bag of opened, unlabeled, and undated chicken cubes was found in the freezer. The bottom shelf of one storage rack in the freezer was not six inches from the floor. There was hardened spilled liquid, food, and dirt under the rack. There were multiple food containers stored on the bottom shelf. On 05/02/22 at 10:02 A.M. these findings were verified by CDM, #284.

Based on review of the Quality Assessment and Assurance (QAA) sign-in sheets and staff interview the facility failed to hold quarterly meetings. This had the potential to affect all 71 residents living in the facility. Findings include: Review of QAA sign-in sheets from 05/01/2021 to 05/01/22 revealed a QAA meeting was held on 04/01/22 for the first quarter of 2022. There was no documentation of QAA sign-in sheets for the last three quarters in 2021. Interview with the Administrator on 05/06/22 at 2:42 P.M. confirmed the missing QAA sign-in sheets for the last three quarters of 2021. The Administrator stated she was new to the facility and was unable to locate the sign-in sheets. Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Plan undated revealed it was the mission of the facility to provide the highest quality of care possible to all those they were privileged to serve.

Based on observation, staff interview, review of the facility's Coronavirus, (COVID-19) policy, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) to prevent the possible spread of COVID-19. This had the potential to affect 21 residents (Resident #14, #21, #24, #27, #31, #32, #33, #41, #42, #43, #44, #46, #48, #54, #58, #64, #65, #171, #172, #173, #174) on the 300 hall. The facility also failed to ensure Legionella water testing laboratory results were addressed in a timely manner. This had the potential to affect 71 residents at the facility. And, the facility failed to ensure infection prevention standards were maintained during wound care. This affected one resident (Resident #62) out of three residents reviewed for pressure ulcer. The facility census was 71. Findings include: 1. Review of the medical record for Resident #174 revealed an admittance date of 05/01/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the baseline assessment dated [DATE] revealed Resident #174 was alert and oriented and required assistance of one staff for ambulation, bed mobility and toileting. Review of the physician orders revealed an order dated 05/02/22 to maintain droplet and contact precautions. Review of Resident #174's immunization record revealed no COVID-19 vaccinations. Observation on 05/02/22 at 10:50 A.M. revealed room [ROOM NUMBER] had a Droplet precaution sign posted on the door and a cart located next to the door that contained PPE items including gowns, gloves, N95 respirators, and surgical masks. A housekeeping cart was in front of the door and Housekeeper #210 was inside cleaning. Housekeeper #210 was wearing a N95 respirator and a face shield but no gown or gloves. Interview on 05/02/22 at 10:55 A.M. with Housekeeper #210 revealed he did not see the sign on the door and did not put on a gown and gloves prior to entering room [ROOM NUMBER]. Housekeeper #210 stated he always wore a gown, gloves, mask, and eye protection when entering a droplet isolation room. Interview on 05/02/22 at 11:20 A.M. with Licensed Practical Nurse (LPN) #277 revealed Resident #174 was in droplet precaution due to being unvaccinated upon arrival to the facility. LPN #277 said the housekeeper was required to wear face shield, N95 mask, gloves and gown when entering a droplet precaution room. Interview with the Director of Nursing (DON) on 05/03/22 at 3:45 P.M. verified the above findings. Review of CDC guidelines titled Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection dated 02/20/22 revealed health care professionals who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to the use of a N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. Review of the CDC COVID Data Tracker dated 04/29/22 through 05/05/22 revealed the community transmission levels for the county which the facility was located was high. Review of the facility policy titled Recommended Personal Protective Equipment for COVID-19 undated revealed staff were required to wear a N95 respirator, eye protection gown and gloves if entering a resident's room on observation for COVID-19 signs and symptoms. 2. Review of the Eco Testing Analytical report dated 04/18/22 revealed samples were taken on 04/05/22 from room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] and the ice machine in the kitchen. The water sample for the ice machine detected 7 colony-forming units in one milliliter (CFU/ml) of Legionella. Interview on 05/04/22 at 9:32 A.M. with Regional Clinical Nurse #292 revealed water samples were obtained and sent out on 04/05/22. The facility received the results on 04/21/22 and the water sample revealed Legionella was detected in the ice machine. Regional Clinical Nurse #292 stated nothing was done with the results until 05/03/22 when the facility received further direction from their corporate office. Regional Clinical Nurse #292 stated on 05/03/22 the ice machine was taken out of service and the filter was changed out. The facility was waiting for retesting supplies to arrive. Regional Clinical Nurse #192 stated that ice from the ice machine was only used to ice food and was not used for consumption. Interview on 05/04/22 at 4:28 P.M. with Corporate Account Manager #193 revealed even the lowest level of Legionella could be a concern and action needed to be taken. The facility had a seven-day protocol to flush fixtures and retest. Flushing removed harmful bacteria and then retesting could take place. Review of the facility policy titled Legionella Analytical Interpretation Guide undated, revealed for levels of 1CFU/ml to 99 CFU/ml immediately review the water treatment program, control measures and risk assessment to develop a remedial action plan. For levels less than 10 CFU's/ml immediately implement corrective action by flushing outlets for 15 minutes. Review of the CDC guidelines titled Legionella (Legionnairs' Disease and Pontiac Fever) revealed there was no safe level or type of Legionella. Performance indicator and suggested response for routine Legionella test result if greater 1 CFU/ml for potable water to implement included the following: 1. Review sample collection, handling, and testing for potential errors. 2. Confirm that system equipment is in good working order and functioning as intended. 3. Review records to confirm that the Water Management Program (WMP) was implemented as designed (verification). 4. Review assumptions about operating conditions, such as physical and chemical characteristics of incoming water. 5. Re-evaluate fundamental aspects of the WMP, including analysis of hazardous conditions, cleaning, maintenance procedures, chemical treatment, and other aspects that could affect Legionella testing. 6. Adjust the WMP as necessary to address any deficiencies identified. 7. Consider whether remedial treatment is need. 3. Review of the medical record of Resident #62 revealed he was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #62's Minimum Data Set assessment dated [DATE] revealed the resident was alert and oriented to time, person and place, required extensive assistance of one to two people for bed mobility, transfers, toilet use and personal hygiene. Review of Resident #62's physician orders dated 04/15/22 revealed an order to cleanse the bottom of the right foot with wound cleanser, pat dry, apply Xeroform (petroleum based gauze), pad with ABD (large gauze pad), and wrap with Kerlix daily and as needed. Observation 05/05/22 at 10:30 A.M. revealed Assistant Director of Nursing (ADON) #274 completing the wound care/dressing change to Resident #62's right foot. After removal of the old dressing, inspection of the bottom of the resident's right foot revealed the entire bottom of the foot was covered with calluses in various places. In the middle of the foot near the center was one open area where according to the ADON the callus had fallen off. The area measured approximately 1 centimeter by 1 cm with no depth. After spraying the wound with wound cleanser, ADON #274 proceeded to pat the wound dry starting at the top of the foot moving down past the open area and then back up the wound using the same side of the pad. ADON #274 then proceeded to dress the wound with Xeroform, covered the area with a thick pad and wrap the entire foot with Kerlix. Interview with ADON #274 after the dressing change was completed on 05/05/22 at 11:00 A.M. verified she patted the wound dry with the same side of the gauze pad up and then down the wound recontaminating the wound. Review of cbi.[NAME].nih.gov revealed make sure you do not reintroduce dirt or ooze by ensuring that cleaning materials are not over-used. Change them regularly and never re-introduce them to a clean area once they have been contaminated.

Based on record review and interview the facility failed to verify financial records, account transactions or quarterly statements were maintained for resident funds. This affected five of five residents (#29, #58, #60, #61, and #65) reviewed for resident funds and had the potential to affect 33 residents (#2, #5, #8, #11, #12, #13, #15, #16, #17, #23, #24, #26, #27, #29, #31, #33, #35, #36, #42, #43, #44, #49, #50, #53, #54, #58, #60, #63, #65, #67, #70) whose funds were managed by the facility. The facility census was 71. Finding include: Review of the Resident Fund Management Service Authorization and Agreement to Handle Resident Funds forms revealed the facility managed the personal funds for Residents #29, #58, #60, #61, and #65. Interview on 05/06/22 at 2:45 P.M. with Business Office Manager (BOM) #294 revealed she had been at the facility for two weeks and did not know how to access the resident's financial records or obtain quarterly statements. The facility was unable to provide resident financial records or access resident statements. They were therefore unable to show if residents with fund accounts accrued interest, received quarterly statements, if residents had access to their funds, or if funds had been returned to a resident's estate as required. Interview on 05/06/22 at 5:29 P.M. with the Administrator verified the facility was unable to provide resident financial documents showing how the facility handled resident funds.

Based on interview and record review the facility failed to ensure participation of the resident and resident's representative in developing the residents comprehensive care plan. This affected six residents (#4, #10, #30, #45, #52, and #70) of seven residents reviewed for care plan participation. The facility census was 71. Findings include: Review of the medical record for Resident #4 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mildly impaired cognition. Review of Resident #4's progress notes and assessments revealed no evidence care conferences had been conducted. Review of the medical record for Resident #10 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment, dated 01/25/22, revealed the resident had intact cognition. Review of Resident #10's progress notes and assessments revealed no evidence care conferences had been conducted. The resident was discharged on [DATE]. Review of the medical record for Resident #30 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS assessment, dated 04/19/22, revealed the resident had mildly impaired cognition. Review of Resident #30's progress notes and assessments revealed the most recent quarterly care conference was held on 02/15/21. Review of the medical record for Resident #45 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment, dated 03/17/22, revealed the resident had severely impaired cognition. Review of progress notes and assessments revealed her last care plan conference was held 05/28/21. Review of the medical record for Resident #52 revealed an admitted [DATE]. Review of the Resident's progress notes and assessments revealed a care plan conference was scheduled for 09/16/21, but there was no record of it being completed. Review of the medical record for Resident #70 revealed an admitted [DATE]. Review of Resident #70's progress notes and assessments revealed no evidence a care conference had been conducted. Interview on 05/04/22 at 10:54 A.M. with Social Service Designee (SSD) #89 revealed she was from another facility and began working at this facility after the facility's previous SSD walked off the job on 05/03/22. The previous SSD had been at the facility approximately a month. An initial care conference was supposed to be scheduled three to five days from admission with the resident and/or representative. Care plan meetings were to be done quarterly. The SSD was to put the notes in the resident's e-medical record in the assessment section or the progress notes section. Interview on 05/04/22 at 11:13 A.M. with the Administrator and Director of Nursing (DON) revealed the previous SSD was at the facility for less than a month, before her there were some gaps in having a SSD in the facility. Interview on 05/06/22 at 9:54 A.M. with the DON and Corporate Clinical Nurse #292 revealed the facility was aware care conferences were to be held quarterly and they had been held sporadically over the last six months to a year. Interview on 05/06/22 at 11:22 A.M. with the Administrator verified she was unable to obtain any information on what residents or resident representatives had care conferences in the last six months.

Based on observation, staff interview, and review of facility drug storage policy and manufacturer's instructions the facility failed to ensure medications were stored according to manufacture guidelines. This affected four residents (Resident #29, #50, #69 and #171) of 71 residents who resided at the facility. Findings include: Observation on [DATE] at 10:00 A.M. of the 300-hallway medication cart revealed an unopened box of nasal spray containing oxymetazoline 0.005 percent, an open bottle Senna-s, a stool softener, a medication cup filled with three round blue tablets, two white oblong pills, one round green tablet, one purple and blue capsule and three and half small round white pills with a piece of paper with a name. Interview on [DATE] at 10:05 A.M. with Licensed Practical Nurse (LPN) #274 revealed she was not assigned to the cart and the nurse who was assigned was on break. LPN #274 verified the findings and stated the medication cup containing the unlabeled medications should have been administered to the resident. Observation on [DATE] at 11:49 A.M. of the 300 and 400 medication room revealed an opened bottle of [MEDICATION(S)] coated aspirin 81 milligram (mg). Observation of the refrigerator revealed an opened multi use vial of [MEDICATION(S)] (PPD) solution, used to detect [CONDITION(S)] disease, with an expiration date of [DATE]. The bottle did not have an open date. Interview on [DATE] at 11:55 A.M. with LPN #241 confirmed the [MEDICATION(S)] vial was open and was not dated as to when it had been opened. Review of the medication list provided by the facility revealed three residents (Resident #29, #50, #69) had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #171 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the manufacturer's instructions for [MEDICATION(S)] (PPD) solution revealed the vial should be refrigerated and protected from light. Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Interview on [DATE] at 4:30 P.M. with the Director of Nursing (DON) verified the above findings. Review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals revised [DATE] revealed the facility should ensure medications and biologicals with an expired date on the label, have been retained longer than recommended by manufactures and supplier guidelines, and have been contaminated/deteriorated, are stored separate from other medication until destroyed or returned to the pharmacy or supplier.

Based on record review and interview the facility failed to ensure the Resident Fund Management Service Authorization and Agreement to Handle Resident Funds form were witnessed for residents whose personal funds were being managed by the facility. This affected one Resident (#58) of five residents (#29, #58, #60, #61, and #65) reviewed for personal funds. The facility census was 71. Findings include: Review of the Resident Fund Management Service Authorization and Agreement to Handle Resident Funds form for Resident #58 revealed the facility failed to have a witnessed authorization form on record for personal funds to be managed by the facility. Interview on 05/06/22 at 4:40 P.M. with Corporate Clinical Nurse #292 confirmed the Resident Fund Management Service Authorization and Agreement to Handle Resident Funds form for Resident #58 was not documented as witnessed.

Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed following resident discharge. This affected two of two residents reviewed for discharge (Residents #1 and #10) . Facility census was 71. Findings include: 1. Review of the closed medical record for Resident #1 revealed an admitted [DATE] and discharge date of [DATE] to the community. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's MDS assessment dated [DATE] revealed the resident had impaired cognition and was expected to discharge to the community. Review of Resident #1's care plan dated 12/14/21 revealed the resident planned to return to the community. Interventions included to involve specialized home care services and provide written instructions upon discharge. Review of the MDS assessment dated [DATE] revealed the assessment was incomplete and had not been submitted. 2. Review of closed medical record for Resident #10 revealed an admitted [DATE] and discharge date of [DATE] to the community. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's quarterly MDS assessment dated [DATE] revealed the resident had intact cognition and was not expected to discharge to the community. Review of Resident #10's care plan dated 01/25/22 revealed the resident planned to return to the community. Interventions included to involve specialized home care services and to provide written instructions upon discharge. Review of the MDS discharge assessment dated [DATE] revealed it was incomplete and had not been submitted. Interview on 05/06/22 at 10:50 A.M. with Corporate Clinical Nurse #292 verified Resident #1's discharge and Resident #10's discharge MDS assessments were incomplete and had not been submitted.

Based on interview and record review the facility failed to have a discharge planning process in place which addressed each resident's discharge goals and included identifying changes in the resident's condition which warranted revising the discharge plan. This affected three of three residents (#4, #10, and #30) reviewed for discharge planning. The facility census was 71. Findings include: Review of the medical record for Resident #4 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mildly impaired cognition. Review of the discharge care plan for Resident #4, dated 09/17/21, revealed discharge status was undetermined because the County had temporary guardianship of Resident #4 due to inability to care for self. Interventions included: Resident will return to appropriate safe placement once stable, assess resident/families' ability to perform transfers and activities of daily living, connect with home health as appropriate, contact and connect with appropriate housing options if applicable, and coordinate discharge planning with community case manager, family, and/or responsible party. The interventions were dated 09/19/21. Review of documents in the medical record of Resident #4 revealed a Statement of Expert Evaluation dated 02/20/22 and an email dated 04/18/22 from the Assistant Prosecuting Attorney, Office of the County Prosecutor discussing the finding of competence. There were no progress notes discussing discharge plans and no evidence care conferences had been conducted. Interview on 05/02/22 at 10:34 A.M. with Resident #4 revealed the resident had been told she was supposed to be leaving the facility and the court was no longer her guardian. Review of the medical record for Resident #10 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment, dated 01/25/22, revealed the resident had intact cognition. Review of Resident #10's progress notes and assessments revealed no evidence care conferences had been conducted. The resident was discharged to another Long-Term Care (LTC) facility on 04/12/22. Review of the discharge care plan for Resident #10, dated 05/27/21, revealed the resident planned to return to the community. Interventions included reevaluate periodically resident's capabilities to return to the community. Review of the last progress note on Discharge Planning/discharge date d 08/31/21 and timed 1:11 A.M. revealed Resident #10 had shown improvement but still had difficulty with moving and using her left side as stated by the resident representative. Resident #10 did not have adequate/safe housing for discharge. The home currently did not have active gas service and the home had anterior and interior steps which limited Resident 10's mobility around the home. Resident #10 was considering leasing an apartment and was to remain in LTC until an adequate home was available for discharge. Review of the medical record for Resident #30 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS assessment, dated 04/19/22, revealed the resident had mildly impaired cognition. Review of Resident #30's progress notes and assessments revealed the most recent quarterly care conference was on 02/15/21. Review of Resident #30's care plans revealed the only plan related to dis charge was dated 11/10/21 and stated the Resident planned to stay long term in the facility. Interventions included: resident will safely adjust to long term care, resident/ family will be actively involved in the resident plan of care, and social services will reevaluate resident's discharge goals periodically. Review of the last progress note on Discharge Planning/discharge date d 08/12/21 and timed 11:58 A.M. revealed Resident #30's family was working with the resident's Medicaid health plan provider to obtain durable medical equipment (DME) and home care services for Resident #30 to return home. They were filing a new request for a waiver assistance as the first claim was denied for failure to show proof of an available home health aide. They continued to utilize available resources to find a suitable home health aide for in home care. Interview on 05/02/22 at 11:37 A.M. with Resident #30 revealed she was ready to go. She needed a new social security card to get a state identification card. Her son wanted her to live with him but Resident #30 didn't want to be in his and his families way. She wanted a place near him. Her niece was going to come stay with her. Interview on 05/04/22 at 10:54 A.M. with Social Service Designee (SSD) #89 revealed she was from another facility and began working at this facility after the previous SSD walked off the job on 05/03/22. The previous SSD had been here approximately a month. SSD #89 revealed Resident #4 had a court appointed temporary guardian for six months. Expert evaluation had recently deemed the resident competent. Interview on 05/04/22 at 11:13 A.M. with the Administrator and Director of Nursing (DON) revealed the previous SSD was at the facility for less than a month, before her there were some gaps in having a SSD in the facility. Interview on 05/06/22 at 9:54 A.M. with the DON and Corporate Clinical Nurse #292 revealed care conferences had been held sporadically over the last six months to a year. Interview on 05/06/22 at 11:22 A.M. with the Administrator verified she was unable to obtain any information on what residents had care conferences in the last six months. Discharge planning was not in the medical record and discharge plans had not been revised as needed.

Based on observation, interview, and record review the facility failed to ensure residents received services to maintain personal and oral hygiene. This affected four (Residents #60, #62, #24, and #44) of 11 residents reviewed for personal hygiene. Facility census was 71. Findings include: 1. Review of medical record revealed Resident #60 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #60's care plan revised on 01/27/22 revealed Resident #60 required extensive assist with one staff to perform personal hygiene. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 required extensive assist with two persons for personal hygiene. Observation on 05/02/22 at 12:59 P.M. revealed Resident #60 lying in bed with a sheet covering her and uncombed greasy hair. Interview with Resident #60 at the time of the observation revealed she received partial bed baths maybe once a week and her hair had not been washed for several months despite having requested to have her hair washed. Interview on 05/04/22 at 9:03 A.M. with Resident #60 revealed she had not had a bed bath since observation on 05/02/22. Interview on 05/04/22 at 1:28 P.M. with State tested Nurse Aide (STNA) #279 revealed Resident #60 loved her bed baths and hair to be washed. Interview on 05/05/22 at 8:54 A.M. with Resident #60 revealed she did not receive a bed bath last night as per bath schedule. Interview on 05/05/22 at 9:01 A.M. with STNA #278 revealed when showers were given, they were recorded in the electronic medical record (EMR) and a shower sheet was filled out and given to the Assistant Director of Nursing (ADON). STNA #278 confirmed Resident #60 was scheduled for a bath last night and there were no shower sheets in the shower book from last night completed for Resident #60. Interview on 05/05/22 at 9:18 A.M. with STNA #285 revealed she received report from the previous shift. If a bath was completed a shower sheet was filled out and the shower is also documented in EMR. She stated Resident #60 had never refused care for her. Interview on 05/05/22 at 1:29 P.M. with the ADON revealed five shower sheets were found for Resident #60 for the past 30 days (03/30/33, 04/04/22, 04/13/22, 04/18/22, and 04/30/22), which was not twice weekly as care planned and any refusals should have been documented in EMR. She stated Resident #60 would receive a bed bath today. Interview on 05/06/22 at 9:19 A.M. with Resident #60 revealed she had not gotten a bath or hair washed last night. Interview on 05/06/22 at 9:26 A.M. with the ADON revealed she had forgotten to alert staff to give Resident #60 a bath and wash hair. She said she would make sure Resident #60 received a bed bath and hair washing this morning. Review of Resident #60 care Kardex revealed bathing was to be completed twice weekly on the night shift, Wednesday and Saturday. Review of the EMR charting bathing task for Resident #60 revealed bed baths were provided three times in the past 30 days on 04/07/22, 04/10/22, and 04/24/22. Review of the facility policy Morning Care/AM Care revised 06/15/20, revealed bath/showers were to be provided as indicated. 2. Review of medical record for Resident #62 revealed Resident #62 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #62's care plan revised on 08/10/21 revealed he had an activities of daily living (ADL) deficit related to stroke with limited range of motion. Review of the MDS assessment dated [DATE] revealed Resident #62 needed a two person assist for personal hygiene. Review of Resident #62's bath/shower sheets revealed he received baths six times (04/13/22, 04/16/22, 04/18/22, 04/20/22, 04/25/22, and 04/30/22) over the past 30 days. Interview on 05/04/22 at 1:28 P.M. with STNA #279 revealed Resident #62 required assistance with bathing and did not usually refuse basic care. Interview on 05/05/22 at 9:01 A.M. with STNA #278 revealed when showers were given, they were recorded in the EMR and a shower sheet was filled out, placed in the shower binder, and given to the ADON. STNA #278 confirmed there were no shower sheets for Resident #62. Interview on 05/05/22 at 9:18 A.M. with STNA #285 revealed she found out who needed bathing from the list in the shower book. Once a bath was done, a shower sheet was filled out and documented in the EMR. Interview on 05/06/22 at 9:26 A.M. with the ADON revealed she had forgotten to alert staff to give Resident #62 a bath and wash hair. She said she would make sure he received a bed bath and hair washing this morning. Observation and interview on 05/06/22 at 9:27 A.M. with Resident #62 revealed his hair was greasy. Resident #62 said he had not received a shower recently. He answered yes when asked if he wanted a bath. Review of the EMR Kardex assignments revealed Resident #62 was scheduled to have bathing on the day shift two times per week on Wednesday and Saturday. Review of EMR charting for Bath Task sheet revealed Resident #62 received one shower over the past 30 days on 05/04/22. Review of the facility policy Morning Care/AM Care revised 06/15/20, revealed bath/showers were to be provided as indicated. 3. Review of medical record revealed Resident #62 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #62's care plan with a revision date of 12/10/18 revealed he was at risk for oral/dental issues related to some missing teeth. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #62 did not have any loose or missing teeth or pain. Review of Resident #62's care Kardex revealed oral care was to be completed twice daily. Observation on 05/02/22 at 10:52 A.M. revealed Resident #62 with reddened gums and visibly unclean teeth with food particles evident between teeth. Interview at the time of the observation with Resident #62 revealed he answered no when asked if staff helped with brushing teeth and said pain when pointing to his teeth. Interview on 05/04/22 at 8:53 A.M. with Resident #62 revealed staff had not set up a toothbrush to brush his teeth and he pointed to his mouth and stated hurts. Interview on 05/04/22 at 11:43 A.M. with State tested Nurse Aide (STNA) #278 revealed Resident #62 could complete his oral care with set up assistance. STNA #278 said staff were to set up what was needed for Resident #62 to complete oral care each day. Interview on 05/04/22 at 1:28 P.M. with STNA #279 revealed Resident #62 would brush teeth with set up and stated Resident #62 did not usually refuse care. Interview on 05/04/22 at 3:09 P.M. with the Director of Nursing (DON) confirmed mouth care was documented as completed once daily eight times (04/05/22, 04/06/22, 04/07/22, 04/08/22, 04/25/22, 04/27/22, 04/28/22, and 04/29/22) for Resident #62's for the past 30 days. Interview on 05/05/22 at 9:16 A.M. with Resident #62 revealed he had not been offered a toothbrush to brush his teeth. He stated it hurt and pointed to his teeth. 4. Review of the medical record for Resident #24 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #24's MDS assessment dated [DATE] revealed Resident #24 had intact cognition and required extensive assistance with personal hygiene. Review of the care plan dated 02/17/22 revealed Resident #24 had a self-care deficit related to right sided weakness. Intervention included to assist with activities of daily living. Review of the physician orders for May 2022 revealed Resident #24 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 05/02/22 at 10:01 A.M. with Resident #24 stated he wanted to see the podiatrist. Observation and Interview on 05/05/22 at 10:10 A.M. with Licensed Practical Nurse (LPN) # 274 of Resident #24's left foot revealed the big toenail was long thick and covered with a white debris that appeared to be fungus. The toenail lifted off the nailbed and was growing in an up and outward position. The toenails on the right and left feet were long thick and covered with a white debris. Interview at this time, with LPN #274 verified Resident #24 required podiatry services. Interview on 05/05/22 at 4:49 P.M. with Social Service Designee (SSD) #289 revealed Resident #24 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. Review of the medical record for Resident #44 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #44's MDS assessment dated [DATE] revealed Resident #44 had impaired cognition and required extensive assistance with personal hygiene. Review of the care plan dated 02/27/22 revealed Resident #44 had self-care deficit related to weakness. Interventions included extensive assistance with bathing and dressing. Observation and interview on 05/02/22 at 4:09 P.M. of Resident's #44's fingernails on both the right and left hands revealed they extended about 0.5 centimeter (cm) from the top of the finger. Several fingernails were broken with jagged edges. Interview at this time with Resident #44, revealed his fingernails were long and need to be cut. Interview with LPN #274 on 05/05/22 at 10:18 A.M. revealed the STNAs and activity staff was responsible for cutting fingernails. LPN #274 verified Resident #44's fingernails needed to be cut. Review of the facility policy titled Morning Care revised on 06/15/20 revealed morning care would be offered each day to promote resident comfort, cleanliness, grooming and general wellbeing.

Based on observation, interview and record review the facility failed to ensure Resident #62 was treated timely for complaints of abdominal pain. This affected one resident (Resident #62) of one resident reviewed for timely treatment. The facility census was 71. Findings include: Review of medical record revealed Resident #62 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 05/05/22 at 9:16 A.M. with Resident #62 revealed that his stomach hurt, he said he was in a lot of pain and he requested medication. This surveyor asked State tested Nurse Aide (STNA) #278 to notify the nurse since the nurse was with another resident. Observation and interview on 05/05/22 at 10:30 A.M. during wound dressing change revealed Resident #62 stated to a second surveyor that he was in pain and requested Milk of Magnesia (MOM). Resident #62 stated the nurse had been previously notified and he was becoming frustrated. The Assistant Director of Nursing (ADON) was present at this time, and she assured Resident #62 his nurse would be notified. Interview on 05/05/22 at 11:42 A.M. with Resident #62 revealed he had not received medication for his stomach and he was still having pain. Licensed Practical Nurse (LPN) #288 was notified by this surveyor and LPN #288 stated she would contact the doctor regarding an order. Interview on 05/05/22 at 12:02 P.M. with LPN #288 revealed she had contacted the doctor and requested an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the nursing progress notes for Resident #62 dated 05/05/22 at 12:02 P.M. revealed a call was placed to the physician for an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #62's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the ADON on 05/06/22 at 2:46 P.M. revealed there was a telephone order for MOM and for an abdominal ultrasound. The ADON verified the MOM was not listed on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the ADON the MOM was given on 05/05/22 at 2:15 P.M.

Based on observation, interview and record review the facility failed to ensure splints ordered by the physician were applied for Resident #7 and #62. This affected two residents (Resident #7 and #62) out of three residents (Resident #7, #32, and #62) reviewed for splints. The facility census was 71. Findings include: 1. Review of medical record revealed Resident #62 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply with morning care and remove as ordered. Assess skin prior to and after application. Complete passive range of motion to fingers and wrist of 10 repetitions with two second holds prior to application as tolerated by resident. Review of Resident #62's plan of care last updated on 02/26/21, revealed Resident #62 had an activities of daily living (ADL) self-care performance deficit related to his stroke and limited range of motion. Interventions included: assist resident with splint during waking hours, encourage use of utensils at meals, praise all efforts of self-care; and right-hand splint to be applied daily for six to eight hours as tolerated by the resident. Observation on 05/02/22 at 10:52 A.M. revealed Resident #62 laying on his back in bed without a right-hand splint. Observation on 05/04/22 at 8:53 A.M. of Resident #62 revealed he did not have the right-hand splint on his right paralyzed arm. Interview on 05/04/22 at 9:19 A.M. with Licensed Practical Nurse (LPN) #205 revealed Resident #62 did not have any ongoing devices that he utilized. Interview on 05/04/22 at 11:43 A.M. with State tested Nurse Aide (STNA) #278 revealed he had not observed and was not aware of a hand splint for Resident #62. Interview on 05/04/22 at 1:28 P.M. with STNA #279 revealed she was not aware of a hand splint for Resident #62 and had never seen one for Resident #62. Interview on 05/04/22 at 2:20 P.M. with LPN #205 revealed staff did not always chart if Resident #62's hand splint was worn. Interview on 05/04/22 at 3:25 P.M. with the Assistant Director of Nursing (ADON) confirmed Resident #62's splint order was still active and verified Resident #62's EMR splint task had missing dates and was not applied as ordered/care planned. Interview on 05/04/22 at 4:27 P.M. with LPN #205 revealed she found Resident #62's splint and stated Resident #62 was capable of removing the splint independently if he desired. Observation on 05/05/22 at 9:16 A.M. of Resident #62 revealed he was not wearing the right-hand splint. Interview on 05/05/22 at 9:18 A.M. with STNA #285 revealed she had never seen a splint nor offered it to Resident #62 to wear. Observation of Resident #62 on 05/05/22 at 11:42 A.M. revealed he was not wearing his right-hand splint. Observation of Resident #62 on 05/06/22 at 9:27 A.M. revealed he was not wearing his right-hand splint. Review of Resident #62's care Kardex revealed right-hand splint to be applied daily for six to eight hours as tolerated during waking hours as resident allows. Review of Resident #62's Treatment Administration Record (TAR) revealed documentation indicating the right hand splint had been worn daily for the past month. Further review of the TAR revealed the right hand splint was signed off as applied on 05/02/22, 05/04/22, 05/05/22, and 05/06/22. There was documentation of Resident #62 refusing to wear the right-hand splint over the past 30 days. Review of Resident #62's EMR splint task revealed application of right-hand splint was to be completed daily and had been applied on six days (04/07/22, 04/08/22, 04/25/22, 04/29/22, and 05/04/22) over the past 30 days. 2. Medical record review revealed Resident #7 was admitted to the facility on [DATE]. Admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The splint was to be applied with morning care and removed with hour of sleep care. Review of Resident #7's Minimum Data Set assessment dated [DATE] revealed Resident #7 was alert and oriented to time, person and place, required extensive assistance of one person for bed mobility, transfers, dressing and toilet use, and was totally dependent on staff for personal hygiene. Observation of Resident #7 on 05/03/22 at 10:30 A.M. revealed Resident #7 was not wearing a left resting hand splint while sitting at the side of his bed. When asked about the splint, Resident #7 said he had not seen the splint, he was not wearing the splint, and did not like wearing the splint. When asked if staff asked him about putting the splint on in the mornings, Resident #7 said no one asked him about putting on the splint. Observation of Resident #7 on 05/04/22 at 12:25 A.M. revealed Resident #7 sitting in a wheelchair with no splint to the left hand. Interview with Director of Therapy Services (DTS) #287 on 05/05/22 at 12:30 P.M. revealed Resident #7 was fitted for a left hand splint to be worn six to eight hours as tolerated. DTS #287 further stated therapy had worked with Resident #7 regarding the splint and tolerating the splint six to eight hours a day which he was able to tolerate. Interview with STNA #278 on 05/05/22 at 1:10 P.M. revealed Resident #7 did not wear a splint. STNA #278 further stated he had not seen a splint in Resident #7's room recently. Observation of Resident #7's room on 05/05/22 at 1:40 P.M. with STNA #256 revealed STNA #256 could not locate a splint in the room. STNA #256 said she never knew Resident #7 was supposed to wear a splint. Interview with LPN #288 on 05/05/22 at 1:55 P.M. revealed she had not seen a splint in Resident #7's room and was not aware he was supposed to wear a splint. Review of Resident #7's care Kardex dated 05/05/22 revealed, under devices, Resident #7 was supposed to have a resting left hand splint six to eight hours a day as tolerated. The splint was to be applied with morning care and removed at bedtime care. Range of motion was to be performed prior to application of the splint.

Based on interview and record review the facility failed to adequately monitor Resident #45's nutritional status and implement actions to prevent ongoing weight loss. This affected one of two residents reviewed (#45 and #66) for weight loss while on enteral feeding. The facility census was 71. Finding include: Review of the medical record for Resident #45 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission nursing assessment identified Resident #45 was admitted with a weight of 202 pounds. Review of the 01/20/22 Dietary Quarterly assessment dated [DATE] revealed Resident #45 had a 9.6 percent significant weight loss at one month and three months, and a 13.9 percent significant weight loss at six months. Review of weights revealed on 12/09/22 Resident #45 weighed 185.5 pounds. On 02/01/22 Resident #45 weighed 163.3 pound, a 11.97 percent loss in two months. On 03/02/22 Resident #45 weighed 166.6 pounds, a 2 percent weight gain. However, the weight loss from 12/09/22 to 03/02/22 was 10.2 percent in three months. Review of the Dietary Quarterly assessment dated [DATE] revealed Resident #45's weight on 03/02/22 was 166.6 pounds. Resident #45 had lost 18.9 pounds, 10.2 percent from 12/09/21 to 03/02/22. No recommendations were made. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/17/22, revealed Resident #45 had severely impaired cognition. Resident #45 received enteral feeding and was totally dependent on staff for receiving nutrition. The assessment indicated Resident #45 weighed 167 pounds and had experienced unplanned weight loss. No weight was obtained in 04/22. There were no nutrition notes after 03/11/22 until identified by the surveyor on 05/04/22. Interview on 05/04/22 at 4:31 P.M. with Registered Dietitian (RD) #268 revealed the RD usually monitored a resident on an enteral feed monthly, or more frequently if they were losing weight. The RD would recommend weekly weights if the resident was experiencing weight loss or other issues. RD #268 verified a weight had not been documented for Resident #45 in 04/22 and no additional monitoring or interventions had been completed. On 05/04/22 Resident #45 was weighed. The resident was at 160.0 pounds. Weights from 12/09/21 to 05/04/22 revealed a significant total weight loss of 25.5 pounds, 13.75 percent weight loss in five months. Review of facility's Weight Policy, last revised 02/01/20, revealed residents were to be weighed weekly for the first four weeks after admission and then monthly or more often if a risk was identified.

Based on observation, record review, and interview the facility failed to provide dental services for one resident (Resident #62) of two residents (Residents #25 and #62) reviewed for dental concerns. The facility census was 71. Findings include: Review of medical record revealed Resident #62 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #62's care plan with a revision date of 12/10/18 revealed he was at risk for oral/dental issues related to some missing teeth. Review of the facility dental service report for Resident #62 revealed last dental visit was on 10/11/21. Review of a note authored by Registered Dietitian (RD) #290 dated 12/21/21 revealed Resident #62 had altered dentition and reported some mouth pain and requested to see the dentist. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #62 did not have any loose or missing teeth or pain. Observation on 05/02/22 at 10:52 A.M. revealed Resident #62 with reddened gums and visibly unclean teeth with food particles evident between teeth. Interview at the time of the observation with Resident #62 revealed he answered no when asked if staff helped with brushing teeth and said pain when pointing to his teeth. Interview on 05/04/22 at 8:53 A.M. with Resident #62 revealed staff had not set up a toothbrush to brush his teeth and he pointed to his mouth and stated hurts. Interview on 05/04/22 at 9:30 A.M. with Certified Occupation Therapy Assistant (COTA) #287 revealed the previous social worker worked for the facility about a month and left job yesterday. COTA #287 stated if a resident wanted an ancillary services appointment, facility staff would let the facility ancillary service know who needed an appointment and set it up. The facility provided quarterly services for podiatry, vision, ear, and dental. Visit notes were emailed to the social worker and uploaded into the electronic medical charting system, Point Click Care (PCC). Interview on 05/04/22 at 11:43 A.M. with State tested Nurse Aide (STNA) #278 revealed Resident #62 could complete his oral care with set up assistance. STNA #278 said staff were to set up what was needed for Resident #62 to complete oral care each day. Interview on 05/04/22 at 1:28 P.M. with STNA #279 revealed Resident #62 would brush his teeth with set up and stated Resident #62 did not usually refuse care. Interview on 05/04/22 at 3:09 P.M. with the Director of Nursing (DON) confirmed mouth care was documented as completed in PCC once daily eight times (04/05/22, 04/06/22, 04/07/22, 04/08/22, 04/25/22, 04/27/22, 04/28/22, and 04/29/22) for Resident #62's for the past 30 days. The DON verified she was notified of the 12/21/21 Registered Dietitian (RD) #290 note with request for dental services. Interview on 05/05/22 at 9:16 A.M. with Resident #62 revealed he had not been offered a toothbrush to brush his teeth. He stated it hurt and pointed to his teeth. Review of the facility Dental Services Policy revised 08/11/20 revealed dental services were available to meet the resident's needs.

Based on record review, review of a facility self-reported incident (SRI), facility policy and procedure review and interview the facility failed to ensure Resident #33 was free from verbal abuse. This affected one resident (#33) of three residents reviewed for abuse, neglect and misappropriation. Findings include: Review of the medical record for Resident #33 revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/01/22 revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated the resident was alert and oriented to person, place, and time. The assessment revealed the resident required assistance from one staff person for the completion of activities of daily living care. Review of a facility Self-Reported Incident (SRI), tracking number 7 revealed on 01/28/21 at approximately 4:00 P.M. Resident #33 made facility staff aware of an allegation of verbal abuse from State tested Nurse Assistant (STNA) #671. Resident #33 revealed STNA #671 stated he gets on her (expletive) nerves and that was why no one (expletive) liked him when he requested who his aide was and for a cup of ice water. Resident #33 declined to file a police report; however, a report was filed by the Administrator. After an investigation by the facility, it was determined the allegation was substantiated and STNA #671's employment was terminated on 02/02/22. On 03/28/22 at 1:24 P.M. interview with the Administrator verified above incident of verbal abuse had occurred involving Resident #33 and the findings of the facility self-reported incident. Review of the facility policy titled Abuse, Neglect, Involuntary Seclusion and Misappropriation, dated 07/14/20 revealed the facility had a policy in place to not tolerate abuse, neglect, mistreatment, exploitation of residents or misappropriation of resident property by anyone. This deficiency substantiates Master Complaint Number OH 060 and Complaint Number OH 891.

Based on closed record review, review of the facility policy and procedure related to physician and provider orders, and interviews with facility staff including Regional Director of Clinical Services (RN) #602 and Licensed Practical Nurse (LPN) #603, the facility failed to provide quality care and treatment for one resident (Resident #72) who was readmitted to the facility on [DATE] following hospitalization with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure Resident #72 received an ordered respiratory inhaler for [CONDITION(S)] for 12 days, failed to administer a diuretic medication that was ordered to give immediately on [DATE], failed to order an ultrasound of the left leg that was ordered STAT (urgently) on [DATE] and failed to monitor Resident #72's vital signs and oxygen saturation level every shift as ordered from [DATE] to [DATE]. This resulted in Immediate Jeopardy when Resident #72 was found on the floor on [DATE] at 4:00 P.M. with respiratory distress symptoms followed by no pulse and respirations requiring the initiation of cardiopulmonary resuscitation (CPR) that was unsuccessful. On [DATE] at 1:12 P.M., the Administrator and Regional Director of Clinical Services #602 were notified Immediate Jeopardy began on [DATE] when Resident #72 was readmitted to the facility from the hospital with physician orders for an inhaler for his [CONDITION(S)] that was not administered from [DATE] to [DATE] and an order to have vital signs with an oxygen saturation level completed every shift which also was not completed from [DATE] to [DATE]. In addition, Nurse Practitioner #607 indicated per her progress note with an effective date as [DATE] at 10:28 A.M. Resident #72 was to receive [MEDICATION(S)] 40 mg now which was not given and an ultrasound to his left leg STAT that was not ordered or completed. Resident #72 was found on the floor with respiratory distress on [DATE] at approximately 4:00 P.M. which was followed by absence of pulse or respirations requiring CPR. Resident #72 expired at the facility following unsuccessful CPR attempts. This affected one (Resident #72) of three residents reviewed for death and implementing physician orders. The facility census was 71. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · Resident #72 no longer resides in the facility. · Identified other potential like residents on [DATE], and all current residents had vital signs completed by the licensed nursing staff on duty (Licensed Practical Nurse (LPN) #614, LPN #615, LPN #616, and Registered Nurse (RN) #617) and recorded in Point Click Care (PCC), all vitals were obtained on [DATE] by 10:00 P.M. The documentation was verified on [DATE] at 10:45 A.M. of all current residents of the facility that vitals and oxygen saturation rates were obtained and recorded in PCC on [DATE]. · All current resident charts were checked on [DATE] by Regional Director of Clinical Services #602 to ensure all orders written including any diagnostic testing have been transcribed into PCC. Any noted to be incomplete were entered and addressed. This audit was completed on [DATE] at 9:30 P.M. The audit was verified on [DATE] at 11:05 A.M. that it had been completed per Regional Director of Clinical Services #602 and that all current resident charts were checked on [DATE] to ensure all orders written including diagnostic testing had been transcribed into PCC. · A report was generated for orders pending confirmation on [DATE] at 5:00 P.M. by Regional Director of Clinical Services #602, any orders noted to be pending for current residents were addressed and confirmed. This was completed [DATE] at 7:00 P.M. by the Regional Director of Clinical Services #602. The report was verified on [DATE] at 11:10 A.M. that it was generated for orders requiring pending confirmation and reviewed per Regional Director of Clinical Services #602 on [DATE] and addressed as needed. · Licensed Nurses were educated on change of condition, documentation, notification and vital signs, Physician / Provider orders, transcription of orders into PCC, and 24-hour chart checks, and medication orders pending confirmation process. Those nurses not on duty were educated via phone. All education was provided and completed by the Regional Director of Clinical Services #602 and Assistant Director of Nursing (ADON)/ LPN #600 on [DATE] at 10:00 P.M. All fourteen nurses currently employed at the facility were in serviced on [DATE]. In service records were verified on [DATE] at 11:20 A.M. and revealed on [DATE] all licensed nurses were educated. Interview on [DATE] from 9:37 A.M. to 11:43 A.M. with Registered Nurse (RN) #625, Licensed Practical Nurse (LPN) #624, #626, and #627 revealed they had received the education on [DATE] and they were knowledgeable regarding change of condition documentation, notification, physician / provider orders, transcription of orders into PCC, and 24- hour chart checks, and medication orders pending confirmation process. · The facility conducted an Ad-hoc Quality Assurance Performance Improvement (QAPI) on [DATE] at approximately 5:45 P.M. to review Action Plan. Participants at the meeting included Medical Director #618 by phone, Administrator, Regional Director of Clinical Services #602, ADON/ LPN #600, Activities Director #619, Maintenance Director #620, RN/ Clinical Manager #621, Receptionist #622, and Business Office Manager #623. The QAPI meeting was verified on [DATE] at 11:33 A.M. that it had occurred on [DATE] and action plan was reviewed. · The DON or ADON/ LPN #600 will monitor documentation of vital signs by auditing three residents medical record three times per week for four weeks for the proper documentation of vital signs within PCC. Any vital signs noted to be lacking will be obtained and documented. Results of the audits will be submitted to the QA committee for further review and recommendations. The audit labeled, Vital Signs Monitoring was reviewed on [DATE] at 11:38 A.M. and verified ADON/ LPN #600 completed the audit on [DATE], and on [DATE] and found no concerns. · The DON or ADON/ LPN #600 will monitor for the completion of 24-hour chart checks by night shift by auditing five charts three times per week for four weeks to ensure chart check signed off and no orders pending transcription. The order listing report will be reviewed in conjunction with this audit to validate transcription of orders into PCC. Any chart checks noted to be lacking or orders noted to not be transcribed will be completed and entered PCC. Results of the audits will be submitted to the QA committee for further review and recommendations. The audit labeled, Chart Check/ Physician Order Transcription Monitoring was verified on [DATE] at 11:45 A.M. and revealed ADON/ LPN #600 completed the audit on [DATE], and on [DATE] and found no concerns. · The DON and ADON/ LPN #600 will monitor physician order confirmation by generating an order pending confirmation report from PCC four times per week for four weeks. Any orders noted to be pending confirmation will be confirmed. Results of the audits will be submitted to the QA committee for further review and recommendation. The audit labeled, Physician Order Confirmation Monitoring was verified on [DATE] at 11:49 A.M. and revealed Regional Director of Clinical Services #602 completed the audit on [DATE] and on [DATE] and found no concerns. · The DON and ADON/ LPN #600 will complete New Admissions / Re-Admission Chart checks following each admission, validating all physician orders, ensuring accurate transcription and confirmation, and documentation of vital signs within PCC. Audit Tools will be reviewed with the QA Committee for further review and recommendation. The audit labeled; Admission/ Readmission Chart Review Audit was verified on [DATE] at 11:51 A.M. and revealed the facility had two recent admissions. Resident #76 was admitted on [DATE] and an audit was completed per ADON/ LPN #600 on [DATE] that revealed no concerns. Resident #75 was admitted on [DATE] and an audit was completed per ADON/ LPN #600 on [DATE] and revealed no concerns. Review of medial record for Resident #75 and #76 revealed no concerns. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Finding include: Review of the closed medical record for the Resident #72 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated [DATE] revealed Resident #72 had altered pulmonary status related to sleep apnea and [CONDITION(S)]. Interventions included administer pharmacological interventions as directed, assess, monitor, and educate resident on signs and symptoms of respiratory distress, elevate head of bed, auscultate breath sounds, and monitor pulse oximetry as indicated. Review of the care plan dated [DATE] revealed Resident #72 had [CONDITION(S)] and potential for impaired airway. Interventions included assess characteristics of cough, auscultate breath sounds, monitor for sign of infection, and pulse oximetry as indicated. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #72 was cognitively intact. He had no behaviors documented. He required supervision with no set-up help with bed mobility, transfers, dressing, and toileting. He was unable to ambulate. He had oxygen while not a resident at the facility but as a resident at the facility, he did not have oxygen. Review of the hospital discharge paperwork labeled, After Visit Summary dated [DATE] revealed Resident #72 was admitted on [DATE] to the hospital as he presented with shortness of breath. Resident #72 had a chest x-ray completed that revealed no pneumonia and he required no oxygen at the hospital. Resident #72 was diagnosed with [CONDITION(S)] with acute exacerbation. Resident #72 was ordered to continue his [MEDICATION(S)] diskus ,d+[DATE] microgram (mcg) dose inhaler inhale one puff as instructed twice daily. Review of the physician orders dated [DATE] revealed Resident #72 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was marked as pending confirmation to discontinue. Resident #72 also had an order dated [DATE] for [MEDICATION(S)] inhaler ,d+[DATE].5 mcg to administer two inhalations by mouth twice daily as this order was submitted electronically per the pharmacy for therapeutic interchange for Resident #72's [MEDICATION(S)], and the order stated pending confirmation. He also had a physician order dated [DATE] to complete respiratory infection screener including a full set of vital signs and oxygen saturation levels every shift. Review of the Medication Administration Record (MAR) dated [DATE] to [DATE] revealed Resident #72 did not receive the [MEDICATION(S)] inhaler as the order on the MAR revealed it was pending because it required confirmation. Resident #72 also did not receive the [MEDICATION(S)] as the order was labeled as discontinued on [DATE] at 5:23 P.M. per the MAR and was pending confirmation. The MAR revealed the nurses checked the respiratory infection screener was completed on the MAR, but there were no vital signs or oxygen saturation levels documented for Resident #72 as ordered. Review of the nursing notes dated [DATE] to [DATE] revealed Resident #72's Primary Care Physician #613, Nurse Practitioners #607 and #608 were not notified regarding Resident #72 not receiving pharmacy recommended therapeutic interchange [MEDICATION(S)] inhaler for [MEDICATION(S)] inhaler, and vital signs or oxygen saturation levels were not completed as ordered. Review of the form labeled Weights and Vitals Summary per Point Click Care (PCC) for vital signs and oxygen saturation levels documentation dated [DATE] to [DATE] for Resident #72 revealed the last documentation was for [DATE] at 5:48 P.M. and revealed the resident's blood pressure was ,d+[DATE], pulse rate 100, respirations 20, oxygen saturation level was 99 percent, and temperature was 97.5 degrees Fahrenheit. There were no other vital signs or oxygen saturation rate documented through [DATE]. Review of the late entry NP #607's Progress Note with a created date of [DATE] at 10:29 P.M. and effective date of [DATE] at 10:28 A.M. revealed she evaluated Resident #72 due to swelling to his left leg which the resident stated started over the weekend. NP #607's progress note revealed Resident #72 was concerned he had a blood clot in his leg as he stated he had a blood clot once before, and this was how it had started. NP #607 revealed the resident's breathing was stable, and he continued to smoke despite education. NP #607 indicated the resident denied fever, chills, fatigue, and pain. NP #607 indicated the resident had mild shortness of breath with cough and his lungs were diminished in the bases with an expiratory wheeze which was chronic. NP #607 ordered a STAT ultrasound to the resident's left lower leg extremity to rule out [CONDITION(S)] (DVT), [MEDICATION(S)] (diuretic) 40 mg now and then every morning and monitor the resident's fluid status. Review of the untimed physician order dated [DATE] and authored by NP #607 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician order was not transcribed by a nurse. Review of the [DATE] MAR for Resident #72 revealed there was no documentation the [MEDICATION(S)] 40 mg was administered on [DATE]. Review of the nursing notes for Resident #72 dated [DATE] revealed no documentation the ultrasound of his lower extremity was ordered. Review of the facility incident report dated [DATE] at 4:00 P.M. and authored by LPN #603 revealed another resident came to the nursing station stating Resident #72 needed the nurse, and LPN #603 went to see what Resident #72 needed. LPN #603 observed Resident #72 on the floor in his room. She assessed and stated he had no apparent deformity or head trauma. LPN #603 administered the Resident #72's inhaler and breathing treatment. The resident received oxygen via nasal cannula. LPN #603 indicated ambulance attendants were in the facility dropping off another resident and were asked to assist with transferring Resident #72 off the floor. During the transfer, Resident #72 stopped breathing and CPR was initiated. LPN #603 indicated Emergency Medical Services (EMS) was called and arrived in approximately eight to ten minutes and took over CPR. The incident report indicated after about 20 minutes of no activity EMS called the hospital to pronounce Resident #72's death. Review of the nursing notes dated [DATE] at 5:04 P.M. revealed Former Licensed Social Worker (LSW) #612 received notification Resident #72 had expired, and she contacted the county corners office to report his death and completed a report by phone. Review of the nursing notes dated [DATE] at 7:55 P.M. and authored by LPN #603 revealed another resident had come to the nursing station stating Resident #72 needed the nurse. LPN #603 went to see what Resident #72 needed and observed Resident #72 on the floor. LPN #603 assessed Resident #72 and provided Resident #72 with a breathing treatment. Resident #72 then stopped breathing and CPR was initiated. EMS and Resident #72's Primary Care Physician #613 were contacted. Interview on [DATE] at 1:11 P.M. with State tested Nursing Assistant (STNA) #604 revealed it was her first day at the facility on [DATE] and she was on orientation. She revealed LPN #603 asked her to assist in getting Resident #72 off the floor, but they were unable. She revealed two ambulance attendants who were dropping off another resident assisted and as they were assisting Resident #72 off the floor, he stopped breathing. STNA #604 indicated they started CPR right away. The STNA stated she had not seen Resident #72 prior to the incident. Interview on [DATE] at 1:20 P.M. with STNA #605 revealed she saw Resident #72 approximately 15 minutes prior to the incident on [DATE] at the nursing station, and he seemed per his usual. She revealed he did not appear to be having any respiratory complications. STNA #605 revealed she had gone to assist another resident with a shower and when she completed the shower, they had started CPR on Resident #72. Interview on [DATE] at 1:27 P.M. with Officer at the Coroner's Office #606 revealed the facility contacted the coroner's office regarding Resident #72, and they reviewed the case and did not recommend any further investigation or autopsy. On [DATE] at 1:43 P.M. an interview was attempted with NP #607 and was unsuccessful. Interview on [DATE] at 1:51 P.M. with NP #608 revealed she was very familiar with Resident #72 as he had [CONDITION(S)], was noncompliant and was in and out of the hospital as he continued to smoke frequently and had respiratory complications as a result. Interview on [DATE] at 2:02 P.M. with LPN #603 revealed Resident #46 came to the nursing station and stated something was wrong with Resident #72. She revealed she knew Resident #72's medical history as he had respiratory difficulties and required an as needed inhaler and aerosol at times when he was short of breath. LPN #603 revealed she grabbed the aerosol treatment ([MEDICATION(S)]- [MEDICATION(S)] solution .,d+[DATE].5 mg/ 3 milliliters (ml) to inhale orally as needed for shortness of breath) and his inhaler ([MEDICATION(S)] aerosol solution two puffs orally as needed for wheezing and shortness of breath) and went to Resident #72's room. LPN #603 revealed Resident #72 was on the floor in front of his wheelchair. She indicated he was excited waving his arms and attempting to tell her something, but it was difficult to understand him. LPN #603 revealed the resident's voice was raspy with a little bit of congestion which was normal for Resident #72. LPN #603 revealed she provided his inhaler as ordered and then his aerosol treatment but during the treatment the resident pushed it away frequently as he attempted to continue to communicate something, but it was still difficult to understand what he was trying to say. LPN #603 revealed she assessed Resident #72 and did not note any injury from the fall and decided to transfer him to his bed to provide comfort and determine what Resident #72 was attempting to communicate. She revealed she had retrieved staff to assist but because of the amputation to his left leg they were unable to transfer from the floor to the bed. LPN #603 indicated they asked two ambulance attendants that were at the facility bringing in a new admission to assist and they assisted with transferring Resident #72 to the bed but as they transferred him to the bed, LPN #603 noticed he was not breathing and had no pulse. LPN #603 revealed she checked to ensure he was a full code, and CPR was initiated. LPN #603 revealed Resident #72 always transferred independently from the bed to the chair and the chair to the bed as well as he was independent with toileting himself. LPN #603 stated she saw Resident #72 approximately 20 minutes prior as he was coming back from a smoke break and had passed the nursing station. The LPN indicated the resident had no respiratory issues at that time. She revealed Resident #72 stated earlier that morning he was going to speak with NP #607 when she arrived due to concerns, but he did not share what those concerns were. She revealed she saw Resident #72 awaiting NP #607's arrival that morning. LPN #603 indicated on interview she was aware Resident #72 was seen by NP #607, and LPN #603 remembered communicating with NP #607 regarding NP #607 writing orders for Resident #72, but LPN #603 could not recall what the orders were. LPN #603 revealed she did not look at what the orders were on his chart. LPN #603 stated she had not given Resident #72 the [MEDICATION(S)] 40 mg that was ordered to give now, and she stated she did not order the ultrasound to the resident's left leg to rule out DVT. LPN #603 could not provide any explanation as to why she did not look at the orders immediately after NP #607 told her new orders had been written. Interview on [DATE] at 2:29 P.M. with Regional Director of Clinical Services # 602 verified Resident #72 had an order to have a respiratory infection screener including a full set of vital signs and oxygen saturation level every shift, and the documentation per the MAR revealed only a check mark was placed on the MAR and no documentation of vital signs or oxygen saturation level was completed from [DATE] to [DATE]. She also verified NP #607 had noted per her progress note dated with an effective date of [DATE] at 10:28 A.M. she had ordered [MEDICATION(S)] 40 mg to be given now and an ultrasound of Resident #72's left leg lower leg STAT. Regional Director of Clinical Services #602 verified there was no documentation the [MEDICATION(S)] was administered, and she verified the ultrasound had not been ordered for Resident #72. Interview on [DATE] at 3:14 P.M. with Resident #46 revealed she was confused at times during the interview as she jumped from one subject to another, but she revealed she was visiting with Resident #72 and he was his wheelchair and started having trouble breathing so he told her to go get the nurse. She revealed she went to the nursing station and told LPN #603 and the LPN went to check Resident #72. Resident #46 revealed Resident #72 was on the floor when LPN #603 went in his room. Interview on [DATE] at 8:59 A.M. and 4:16 P.M. with Regional Director of Clinical Services #602 verified on return from the hospital on [DATE] Resident #72 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She revealed the pharmacy went into the PCC system on [DATE] and electronically transmitted a therapeutic interchange by recommending Resident #72's [MEDICATION(S)] be discontinued and to initiate [MEDICATION(S)] inhaler ,d+[DATE].5 mcg two inhalations by mouth twice daily. Regional Director of Clinical Services #602 revealed the pharmacy was waiting on confirmation and until confirmation was received the order would not generate on the MAR to administer the medication. Regional Director of Clinical Services #602 revealed the pending confirmation required a nurse to go into the system and push the approval after confirming the order with Resident #72's Primary Care Physician #613. Regional Director of Clinical Services #602 verified this was not completed and from [DATE] to [DATE] Resident #72 did not receive [MEDICATION(S)] or the recommended therapeutic interchange of [MEDICATION(S)] inhaler for his [CONDITION(S)]. She verified Resident #72's Primary Care Physician #613 was not notified that Resident #72 was not receiving either the [MEDICATION(S)] or the substitute [MEDICATION(S)] for his [CONDITION(S)]. Review of the form labeled Order Audit Report dated [DATE] at 4:13 P.M. revealed Resident #72 had an order dated [DATE] at 5:38 P.M. for [MEDICATION(S)] ,d+[DATE].5 mcg inhaler to give two inhalations by mouth twice a day that was electronically transmitted from pharmacy for a therapeutic interchange for [MEDICATION(S)] Discus aerosol powder breath activated ,d+[DATE] mcg one puff orally every 12 hours for breathing. The order on the audit report revealed pending confirmation. Review of facility policy titled Physician/ Provider Orders dated [DATE] revealed the nurse shall transcribe and review all physician and provider orders. The policy revealed on admission all orders from the transfer form would be transcribed including medications and treatments. The policy revealed the attending physician would review and confirm the orders on admission, but the policy did not include how therapeutic interchanges recommended per the pharmacy would be processed and confirmed. The policy did not include how orders including vitals and oxygen saturation level would be documented or if a physician ordered a medication to be given now or a procedure to be obtained STAT how that order would be transcribed, administered, and/ or ordered. This deficiency substantiates Complaint Number OH 454.

Based on closed record review, review of the facility policy and procedure related to physician and provider orders, and interviews with facility staff including Regional Director of Clinical Services (RN) #602 and Licensed Practical Nurse (LPN) #603, the facility failed to ensure one resident (Resident #72) who was readmitted to the facility on [DATE] following hospitalization with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure Resident #72 received an ordered respiratory inhaler for [CONDITION(S)] for 12 days and failed to administer a diuretic medication that was ordered to be given immediately on [DATE]. This resulted in Immediate Jeopardy when Resident #72 was found on the floor on [DATE] at 4:00 P.M. with respiratory distress symptoms followed by no pulse and respirations requiring the initiation of cardiopulmonary resuscitation (CPR) that was unsuccessful. On [DATE] at 1:12 P.M., the Administrator and Regional Director of Clinical Services #602 were notified Immediate Jeopardy began on [DATE] when Resident #72 was readmitted to the facility from the hospital with physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, Nurse Practitioner #607 indicated per her progress note with an effective date as [DATE] at 10:28 A.M. Resident #72 was to receive [MEDICATION(S)] 40 mg now which was not given. Resident #72 was found on the floor with respiratory distress on [DATE] at approximately 4:00 P.M. which was followed by absence of pulse and respirations requiring CPR. Resident #72 expired at the facility following unsuccessful CPR attempts. This affected one (Resident #72) of three residents reviewed for significant medication errors. The facility census was 71. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · Resident #72 no longer resides in the facility. · All current resident charts were checked on [DATE] by Regional Director of Clinical Services #602 to ensure all orders written including any diagnostic testing have been transcribed into PCC. Any noted to be incomplete were entered and addressed. This audit was completed on [DATE] at 9:30 P.M. The audit was verified on [DATE] at 11:05 A.M. that it had been completed per Regional Director of Clinical Services #602 and that all current resident charts were checked on [DATE] to ensure all orders written including diagnostic testing had been transcribed into PCC. · A report was generated for orders pending confirmation on [DATE] at 5:00 P.M. by Regional Director of Clinical Services #602, any orders noted to be pending for current residents were addressed and confirmed. This was completed [DATE] at 7:00 P.M. by the Regional Director of Clinical Services #602. The report was verified on [DATE] at 11:10 A.M. that it was generated for orders requiring pending confirmation and reviewed per Regional Director of Clinical Services #602 on [DATE] and addressed as needed. · Licensed Nurses were educated on change of condition documentation, notification, Physician / Provider orders, transcription of orders into PCC, and 24-hour chart checks, and medication orders pending confirmation process. Those nurses not on duty were educated via phone. All education was provided and completed by the Regional Director of Clinical Services #602 and Assistant Director of Nursing (ADON)/ LPN #600 on [DATE] at 10:00 P.M. All fourteen nurses currently employed at the facility were in serviced on [DATE]. In service records were verified on [DATE] at 11:20 A.M. and revealed on [DATE] all licensed nurses were educated. Interview on [DATE] from 9:37 A.M. to 11:43 A.M. with Registered Nurse (RN) #625, Licensed Practical Nurse (LPN) #624, #626, and #627 revealed they had received the education on [DATE] and they were knowledgeable regarding change of condition documentation, notification, physician / provider orders, transcription of orders into PCC, and 24- hour chart checks, and medication orders pending confirmation process. · The facility conducted an Ad-hoc Quality Assurance Performance Improvement (QAPI) on [DATE] at approximately 5:45 P.M. to review Action Plan. Participants at the meeting included Medical Director #618 by phone, Administrator, Regional Director of Clinical Services #602, ADON/ LPN #600, Activities Director #619, Maintenance Director #620, RN/ Clinical Manager #621, Receptionist #622, and Business Office Manager #623. The QAPI meeting was verified on [DATE] at 11:33 A.M. that it had occurred on [DATE] and action plan was reviewed. · The DON or ADON/ LPN #600 will monitor for the completion of 24-hour chart checks by night shift by auditing five charts three times per week for four weeks to ensure chart check signed off and no orders pending transcription. The order listing report will be reviewed in conjunction with this audit to validate transcription of orders into PCC. Any chart checks noted to be lacking or orders noted to not be transcribed will be completed and entered PCC. Results of the audits will be submitted to the QA committee for further review and recommendations. The audit labeled, Chart Check/ Physician Order Transcription Monitoring was verified on [DATE] at 11:45 A.M. and revealed ADON/ LPN #600 completed the audit on [DATE], and on [DATE] and found no concerns. · The DON and ADON/ LPN #600 will monitor physician order confirmation by generating an order pending confirmation report from PCC four times per week for four weeks. Any orders noted to be pending confirmation will be confirmed. Results of the audits will be submitted to the QA committee for further review and recommendation. The audit labeled, Physician Order Confirmation Monitoring was verified on [DATE] at 11:49 A.M. and revealed Regional Director of Clinical Services #602 completed the audit on [DATE] and on [DATE] and found no concerns. · The DON and ADON/ LPN #600 will complete New Admissions / Re-Admission Chart checks following each admission, validating all physician orders, ensuring accurate transcription and confirmation, and documentation of vital signs within PCC. Audit Tools will be reviewed with the QA Committee for further review and recommendation. The audit labeled; Admission/ Readmission Chart Review Audit was verified on [DATE] at 11:51 A.M. and revealed the facility had two recent admissions. Resident #76 was admitted on [DATE] and an audit was completed per ADON/ LPN #600 on [DATE] that revealed no concerns. Resident #75 was admitted on [DATE] and an audit was completed per ADON/ LPN #600 on [DATE] and revealed no concerns. Review of medial record for Resident #75 and #76 revealed no concerns. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Finding include: Review of the closed medical record for the Resident #72 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated [DATE] revealed Resident #72 had altered pulmonary status related to sleep apnea and [CONDITION(S)]. Interventions included administer pharmacological interventions as directed, assess, monitor, and educate resident on signs and symptoms of respiratory distress, elevate head of bed, auscultate breath sounds, and monitor pulse oximetry as indicated. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #72 was cognitively intact. He had oxygen while not a resident at the facility but as a resident at the facility, he did not have oxygen. He received no diuretics during this assessment period. Review of the hospital discharge paperwork labeled, After Visit Summary dated [DATE] revealed Resident #72 was admitted on [DATE] to the hospital where he presented with shortness of breath. Resident #72 had a chest x-ray completed that revealed no pneumonia and he required no oxygen at the hospital. Resident #72 was diagnosed with [CONDITION(S)] with acute exacerbation. Resident #72 was ordered to continue his [MEDICATION(S)] diskus ,d+[DATE] microgram (mcg) dose inhaler inhale one puff as instructed twice daily. Review of the physician orders dated [DATE] revealed Resident #72 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was marked as pending confirmation to discontinue. Resident #72 also had an order dated [DATE] for [MEDICATION(S)] inhaler ,d+[DATE].5 mcg to administer two inhalations by mouth twice daily as this order was submitted electronically per the pharmacy for therapeutic interchange for Resident #72's [MEDICATION(S)], and the order stated pending confirmation. Review of the Medication Administration Record (MAR) dated [DATE] to [DATE] revealed Resident #72 did not receive the [MEDICATION(S)] inhaler as the order on the MAR revealed it was pending because it required confirmation. Resident #72 also did not receive the [MEDICATION(S)] as the order was labeled as discontinued on [DATE] at 5:23 P.M. per the MAR and was pending confirmation. Review of the nursing notes dated [DATE] to [DATE] revealed Resident #72's Primary Care Physician #613, Nurse Practitioners #607 and #608 were not notified regarding Resident #72 not receiving pharmacy recommended therapeutic interchange [MEDICATION(S)] inhaler for [MEDICATION(S)] inhaler. Review of the late entry NP #607's Progress Note with a created date of [DATE] at 10:29 P.M. and effective date of [DATE] at 10:28 A.M. revealed she evaluated Resident #72 due to swelling to his left leg which the resident stated started over the weekend. NP #607 indicated the resident denied fever, chills, fatigue, and pain. NP #607 indicated the resident had mild shortness of breath with cough and his lungs were diminished in the bases with an expiratory wheeze which was chronic. NP #607 ordered [MEDICATION(S)] (diuretic) 40 mg now and then every morning. Review of the untimed physician order dated [DATE] and authored by NP #607 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician order was not transcribed by a nurse. Review of the [DATE] MAR for Resident #72 revealed there was no documentation the [MEDICATION(S)] 40 mg was administered on [DATE]. Review of the facility incident report dated [DATE] at 4:00 P.M. and authored by LPN #603 revealed another resident came to the nursing station stating Resident #72 needed the nurse, and LPN #603 went to see what Resident #72 needed. LPN #603 observed Resident #72 on the floor in his room. She assessed and stated he had no apparent deformity or head trauma. LPN #603 administered Resident #72's inhaler and breathing treatment. The resident received oxygen via nasal cannula. LPN #603 indicated ambulance attendants were in the facility dropping off another resident and were asked to assist with transferring Resident #72 off the floor. During the transfer, Resident #72 stopped breathing and CPR was initiated. LPN #603 indicated Emergency Medical Services (EMS) was called and arrived in approximately eight to ten minutes and took over CPR. The incident report indicated after about 20 minutes of no activity EMS called the hospital to pronounce Resident #72's death. On [DATE] at 1:43 P.M. an interview was attempted with NP #607 and was unsuccessful. Interview on [DATE] at 2:02 P.M. with LPN #603 revealed Resident #46 came to the nursing station and stated something was wrong with Resident #72. LPN #603 revealed she knew Resident #72's medical history as he had respiratory difficulties and required an as needed inhaler and aerosol at times when he was short of breath. LPN #603 revealed she grabbed the aerosol treatment ([MEDICATION(S)]- [MEDICATION(S)] solution .,d+[DATE].5 mg/ 3 milliliters (ml) to inhale orally as needed for shortness of breath) and his inhaler ([MEDICATION(S)] aerosol solution two puffs orally as needed for wheezing and shortness of breath) and went to Resident #72's room. LPN #603 revealed Resident #72 was on the floor in front of his wheelchair. She indicated he was excited waving his arms and attempting to tell her something, but it was difficult to understand him. LPN #603 revealed the resident's voice was raspy with a little bit of congestion which was normal for Resident #72. LPN #603 revealed she provided his inhaler as ordered and then his aerosol treatment but during the treatment the resident pushed it away frequently as he attempted to continue to communicate something, but it was still difficult to understand what he was trying to say. LPN #603 revealed she assessed Resident #72 and did not note any injury from the fall and decided to transfer him to his bed to provide comfort and determine what Resident #72 was attempting to communicate. She revealed she had retrieved staff to assist but because of the amputation to his left leg they were unable to transfer from the floor to the bed. LPN #603 indicated they asked two ambulance attendants that were at the facility bringing in a new admission to assist and they assisted with transferring Resident #72 to the bed but as they transferred him to the bed, LPN #603 noted he was not breathing and had no pulse. LPN #603 revealed she checked to ensure he was a full code, and CPR was initiated. LPN #603 revealed Resident #72 always transferred independently from the bed to the chair and the chair to the bed as well as he was independent with toileting himself. LPN #603 stated she saw Resident #72 approximately 20 minutes prior as he was coming back from a smoke break and had passed the nursing station. LPN #603 indicated the resident had no respiratory issues at that time. She revealed Resident #72 stated earlier that morning he was going to speak with NP #607 when she arrived due to concerns, but he did not share what those concerns were. She revealed she saw Resident #72 awaiting NP #607's arrival that morning. LPN #603 indicated on interview she was aware Resident #72 had seen NP #607 and LPN #603 remembered communicating with NP #607 regarding NP #607 writing orders for Resident #72, but LPN #603 could not recall what the orders were. LPN #603 revealed she did not look at what the orders were on his chart. LPN #603 stated she had not given Resident #72 the [MEDICATION(S)] 40 mg that was ordered to give now. LPN #603 could not provide any explanation as to why she did not look at the orders after NP #607 told her new orders had been written. Interview on [DATE] at 2:29 P.M. with Regional Director of Clinical Services # 602 verified NP #607 had noted per her progress note dated with an effective date of [DATE] at 10:28 A.M. she had ordered [MEDICATION(S)] 40 mg to be given now and then 40 mg every morning daily. Regional Director of Clinical Services #602 verified there was no documentation the [MEDICATION(S)] was administered for Resident #72. Interview on [DATE] at 8:59 A.M. and 4:16 P.M. with Regional Director of Clinical Services #602 verified on return from the hospital on [DATE] Resident #72 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She revealed the pharmacy went into the PCC system on [DATE] and electronically transmitted a therapeutic interchange by recommending Resident #72's [MEDICATION(S)] be discontinued and to initiate [MEDICATION(S)] inhaler ,d+[DATE].5 mcg two inhalations by mouth twice daily. Regional Director of Clinical Services #602 revealed the pharmacy was waiting on confirmation and until confirmation was received the order would not generate on the MAR to administer the medication. Regional Director of Clinical Services #602 revealed the pending confirmation required a nurse to go into the system and push the approval after confirming the order with Resident #72's Primary Care Physician #613. Regional Director of Clinical Services #602 verified this was not completed and from [DATE] to [DATE] Resident #72 did not receive [MEDICATION(S)] or the recommended therapeutic interchange of [MEDICATION(S)] inhaler for his [CONDITION(S)]. She verified Resident #72's Primary Care Physician #613 was not notified that Resident #72 was not receiving either the [MEDICATION(S)] or the substitute [MEDICATION(S)] for his [CONDITION(S)]. Review of the form labeled Order Audit Report dated [DATE] at 4:13 P.M. revealed Resident #72 had an order dated [DATE] at 5:38 P.M. for [MEDICATION(S)] ,d+[DATE].5 mcg inhaler to give two inhalations by mouth twice a day that was electronically transmitted from pharmacy for a therapeutic interchange for [MEDICATION(S)] Discus aerosol powder breath activated ,d+[DATE] mcg one puff orally every 12 hours for breathing. The order on the audit report revealed pending confirmation. Review of facility policy titled Physician/ Provider Orders dated [DATE] revealed the nurse shall transcribe and review all physician and provider orders. The policy revealed on admission all orders from the transfer form would be transcribed including medications and treatments. The policy revealed the attending physician would review and confirm the orders on admission, but the policy did not include how therapeutic interchanges recommended per the pharmacy would be processed and confirmed. The policy did not if a physician ordered a medication to be given now how that order would be transcribed and administered. This deficiency substantiates Complaint Numbers OH 454.

Based on medical record review, observation, interviews with staff, review of the facility's incident investigation, review of the National Weather Service computerized environmental temperatures, and review of a police incident report, the facility failed to ensure adequate supervision was provided to prevent the elopement of a resident with serious mental illness and a history of hypothermia in subzero temperatures. This resulted in Immediate Jeopardy when Resident #94 left the facility without staff knowledge. Actual harm occurred when Resident #94 was found approximately two miles away from the facility, frozen and deceased by the local police eight hours after he was last seen at the facility. This affected one of 31 independently ambulatory residents with serious mental illness (Residents #5, #2, #11, #12, #26, #31, #37, #40, #42, #44, #45, #46, #47, #48, #49, #50, #54, #57, #63, #69, #74, #75, #80, #81, #82, #84, #85, #90, #91, #93, #94). The facility identified four residents as being at risk of elopement (Residents #2, #5, #76 and #80). On [DATE] at 5:12 P.M., the Administrator, Director of Nursing (DON), Administrator in Training (AIT), Assistant Director of Nursing (ADON), Corporate Registered Nurse (RN) #109, and Corporate RN #110 were notified Immediate Jeopardy began on [DATE] at approximately 12:30 A.M., when it was discovered the window in room [ROOM NUMBER] was open with foot prints noted in the snow outside the window leading away from the building. A head count was completed between 12:45 A.M and 12:50 A.M. Resident #94 was identified as missing and an external search of the facility was initiated. Despite the negative (-) 4 degrees Fahrenheit (F) air temperatures with a wind chill of -10 F, the local police department was not notified until 1:53 A.M. On [DATE] at 9:00 A.M. the Administrator was notified the police located a body, and at 9:15 A.M. the Administrator positively identified the body of Resident #94. The Immediate Jeopardy was removed on [DATE] at 4:00 P.M. when the facility implemented the following corrective action: · On [DATE] at 8:00 A.M., cracked windows in Rooms 101, 102, 105, 201, 206, 210, 213, 307, 405 and 409 were temporarily taped for securement by RN #108, Director of Maintenance (DM) #114 and Regional Vice President of Operations (RVPO) #127. An outside window vendor was contacted to measure windows for repair. · On [DATE] at 8:30 A.M., DM #114 completed a whole house door audit to check the function of the wanderguard system (a system in which a resident wears a bracelet and when the resident nears a protected door an alarm sounds) on each door with all doors functioning as designed. · On [DATE] at 11:00 A.M. the Administrator, RN #108 and RN #109 completed review of all residents to determine residents who did not consistently follow the leave of absence (LOA) policy and procedure. Two residents (Residents #40 and #64) were identified, and these residents were re-educated on the LOA policy and procedure. All resident LOA care plans were reviewed and updated as appropriate. · On [DATE] at 11:00 A.M., Social Service Director (SSD) #104 reviewed the elopement binder with updates made as indicated. The elopement binder will be reviewed weekly by SSD #104 and updated as indicated. · On [DATE] at 12:00 P.M., the DON reviewed all elopement assessments to validate the accuracy of each assessment with new assessments completed as indicated and validated the four residents (Residents #2, #5, #76 and #80) with physician ordered wanderguards had the wanderguards in place and they functioned as designed. · On [DATE] at 2:45 P.M. and 4:40 P.M., DM #114 conducted elopement drills. Staff response was noted to be appropriate and timely. · On [DATE] at 3:00 P.M., the DON completed a review of all residents with orders for LOAs (Residents #6, #11, #20, #24, #32, #44, #54, #64, #73 and #84) with recommendations made to the physician for order changes as appropriate. · On [DATE] at 4:00 P.M., DM #114 completed a whole house window audit with additional screws added to ensure windows would not open more than six inches. · On [DATE] at 4:00 P.M., the AIT educated all alert and oriented residents regarding on what to do if they were aware of a resident voicing/wanting to leave the facility or if they saw a resident leaving the facility. The AIT also provided education regarding the LOA process. · On [DATE] at 4:50 P.M., an Ad-hoc Quality Assurance Performance Improvement (QAPI) meeting was held. Attendance included the Administrator, DON, ADON and Medical Director. · On [DATE] between 5:00 A.M. and 7:00 P.M., all staff on all shifts including nursing, dietary, maintenance/housekeeping, therapy, business office staff, scheduling, etc. were reeducated on the elopement and LOA policies and procedures by the DON, ADON, Administrator, RN #108, RN #109 and the AIT. · On [DATE] at 8:00 P.M., Regional Reimbursement Specialist (RRS) #126 reviewed all current resident care plans to ensure accuracy and appropriate interventions for residents at risk for elopement. · On [DATE] at 11:45 PM., RN #105 conducted an elopement drill. Staff response was noted to be appropriate and timely. · On [DATE] at 4:00 P.M., DM #114, Housekeeper (HSK) #116, and the Administrator secured the cracked windows in Rooms 101, 102, 105, 201, 206, 210, 213, 307, 405 and 409 with dry wall. · Beginning [DATE], DM #114 or HSK #116 will complete daily door audits with adverse findings addressed as indicated. · Beginning [DATE], DM #114 or designee will complete daily window checks (to include window in good repair and no greater than six-inch opening) for one month and then monthly for two months. · Beginning [DATE], SSD #104 will interview five alert and oriented residents weekly to determine knowledge of LOA policy and procedure for four weeks then five per month for two months. · Beginning [DATE], SSD #104 or designee will review residents that go out for LOAs five times a week for four weeks and conduct comparison to the sign out log. If a resident is found to be noncompliant with the LOA process, re-education will be provided. · The results of all audits will be submitted to the facility QAPI committee for further review and recommendation. · On [DATE] at 10:25 A.M, interviews with Licensed Practical Nurse (LPN) #100, at 11:08 A.M., State tested Nursing Assistant (STNA) #105 at 12:41 P.M., RN #102 at 1:00 P.M. and RN #108 at 3:47 P.M. revealed the staff had received education on [DATE] regarding elopement and LOA policies and procedures. Each was knowledgeable regarding the policies and procedures. · On [DATE] at 8:22 A.M., interviews with STNA #118, at 8:35 A.M. HSK #117, at 8:50 A.M. Dietary Manager #120 and at 9:18 A.M. Physical Therapist #121 revealed the staff had received education on [DATE] regarding elopement and LOA policies and procedures. Each was knowledgeable regarding the policies and procedures. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was in the process of completing and reviewing audits to determine further action if required. Findings include: Record review revealed Resident #94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medications included [MEDICATION NAME] Sodium 500 milligrams (mg) twice a day (bid) for mood stabilization, Eliquis 2.5 mg bid for anticoagulation, Levetiracetam 500 mg bid and [MEDICATION NAME] 250 mg bid for [MEDICAL CONDITION]. Review of Resident #94's elopement assessment dated [DATE] revealed the resident was physically capable of leaving the facility, was not alert and oriented and had no prior history of exit seeking, nor was he exit seeking. Review of physician orders [REDACTED].#94's wanderguard. Review of Resident #94's care plan dated [DATE] revealed the resident was at risk for bleeding/bruising, elopement, altered behaviors and mood, pain related to toe amputation, falls, depression and anxiety. The care plan included a goal of not leaving the facility unattended. Resident #94 was only allowed supervised leave of absences (LOA) related to psychiatric [DIAGNOSES REDACTED]. Further review of the plan of care revealed interventions for risk of elopement last updated [DATE], included activities to keep the resident occupied, redirection, diverting attention, relocating resident to a different area and a wanderguard with a goal of not leaving the facility unattended. Interventions for supervised leave of absence related to psychiatric [DIAGNOSES REDACTED]. resident to give smoking materials back to staff upon return from LOA, resident and responsible party sign in and out and notify nursing when leaving facility, and review of LOA policy upon admission and as needed. Goals for supervised LOA included resident would remain safe while out of facility as evidenced by no falls, bodily harm or use of unauthorized substances, resident would follow leave of absence procedure per policy, and resident would participate in LOA with family/friends and follow facility LOA rules. Review of Resident #94's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, based on the brief interview mental status score of 13, had daily physical behaviors not directed towards others, required setup and supervision only for most activities of daily living (ADL), and was frequently incontinent of bladder and bowel. Review of the facility's undated investigation of the ' unauthorized leave ' revealed Resident #94 exited the building sometime after 11:30 P.M. on [DATE] via the window in room [ROOM NUMBER]. The L bracket securing the window was bent down allowing the window to be opened wide enough for the resident to exit. Footprints were seen under the window leading away from the building. The facility investigation concluded the alert and oriented resident made a cognitive decision to exit the facility in the subzero temperatures. The facility investigation concluded the facility could not have foreseen the resident would damage a window bracket and leave the facility. The investigation did not include the dress of the resident. Tour of the facility on [DATE] at 10:15 A.M. revealed Resident #94's room (room [ROOM NUMBER]) had a three paned sliding window. The middle section had a screen that was torn the entire width along the bottom and two inches up. The tear was covered with silver colored duct tape. The window could not be opened more than four inches because screws had been placed vertically into the window frame. The window looked out onto an enclosed patio. Observation of room [ROOM NUMBER], the room directly across from Resident #94's room revealed a three paned window. One of three panes had large cracks covered with blue masking tape. One crack extended the full width of the window, another extended three fourths of the way to the top of the window and a third which began mid-window extended to the bottom of the window. Observation of the window in room [ROOM NUMBER], the window which Resident #94 used to exit the facility, revealed a L bracket flat against the frame with two screws placed vertically in front of the L bracket and a third screw noted in the upper frame. The window could not be opened more than four inches. The window did not have a screen. Observation directly outside the window revealed two large foot prints leading away from the building toward a grassy area which led to a walkway to the street. Interview on [DATE] at 10:25 A.M. with LPN #100 revealed she last saw Resident #94 at approximately 11:15 P.M. on [DATE] when he asked her for a cigarette lighter. LPN #100 reminded the resident of the smoking policy and he cursed at her under his breath and walked away. LPN #100 said Resident #94 refused his night time medications earlier in the evening. LPN #100 indicated she was called to room [ROOM NUMBER] by STNA #100 on [DATE] at approximately 12:30 A.M. While doing rounds, STNA #100 discovered an open window in room [ROOM NUMBER] which was not Resident #94's room. The window was open, the L bracket was bent flat in the window tract, and the screen was lying in the snow. There were footprints in the snow leading away from the window. LPN #100 alerted the nursing supervisor, RN #102, and a head count was conducted starting at approximately 12:45 A.M. Resident #94 was the only resident not located. After the head count was completed LPN #100 drove her car in the immediate area looking for Resident #94. LPN #100 reported the administrator was notified at 1:45 A.M. and instructed staff to call the police. The police were called at 1:53 A.M. and arrived at 2:15 A.M. LPN #100 was not aware of any protocol for checking the security of the windows. Interview on [DATE] at 10:36 A.M. with DM #114 revealed the L brackets in the resident room windows had been placed in the windows a year or two ago. Screws were added yesterday, [DATE], after the elopement to reinforce the L brackets. He indicated the L bracket in room [ROOM NUMBER] had been bent flat which allowed the resident to open the window and exit the facility. The facility did not have a maintenance schedule to ensure the L brackets were maintained to prevent the windows from opening more than six inches and he could not say the last time the windows had been audited. Interview on [DATE] at 10:45 A.M. with SSD #104 revealed Resident #94 had a history of [REDACTED]. The resident was sent to the hospital twice in the past month for being physically aggressive with other residents and refused psychiatric services at the facility. SSD #104 was in the process of finding a facility to transfer the resident to which was better prepared to deal with aggressive behaviors. SSD #104 reported the resident was cognitively intact and his own guardian but used bad judgement in exiting the facility through a window in subzero weather. SSD #104 confirmed the resident did not have independent leave of absence privileges, per physician orders. Interview on [DATE] at 11:08 A.M. with RN #102, the nursing supervisor for the night shift who monitored the 11:30 P.M. smoke break, revealed she last saw the resident at the 11:30 P.M. smoke break in the indoor smoking room on [DATE]. The smoke break lasted until approximately 12:15 A.M. on [DATE]. RN #102 was not sure what time Resident #94 left the smoke room but stated the resident was dressed in a hoodie, jeans and tennis shoes. RN #102 reported the resident always walked the halls of the building and had a couple aggressive episodes in the past month resulting in trips to the hospital. RN #102 was unable to explain why the administrator was not called until 1:45 A.M. or why the police were not called when the footprints were noticed outside in the subzero weather. RN #102 was not aware of a protocol for checking the security of the windows. Interview on [DATE] at 12:41 P.M. with STNA #107, who worked second shift on the resident ' s unit and was working on the night of the incident, revealed Resident #94 had poor memory and decision making and walked throughout the building. STNA #107 was not aware of any protocol for checking the security of the windows. Interview on [DATE] at 1:00 P.M. with the ADON revealed the facility was working on transferring Resident #94 due to recent aggressive behavior. The resident had a wanderguard upon admission as a safeguard, but the order was discontinued by the physician on [DATE]. RN #106 did not know why the wanderguard was discontinued by the physician when it was still listed as an intervention on the resident ' s care plan. The ADON said Resident #94 was his own guardian and had the right to make bad decisions including exiting the facility in subzero weather without the proper clothing, a decision that lead to his death. The ADON verified Resident #94 did not have independent leave of absence privileges. The ADON was not aware of any protocol for checking the security of the windows. Interviews on [DATE] with LPN #111 at 3:09 P.M., RN #112 at 3:20 P.M. and LPN #113 at 3:42 P.M. revealed they were the charge nurses who completed all elopement assessments. When completing an elopement assessment, they assessed for exit seeking behavior, previous elopement, cognition/dementia, and if the resident had expressed wanting to go home or an urgency to leave. They did not assess for the resident's insight, judgment, or ability/ history of making safe decisions. The physician assessed residents for their decision-making abilities when determining if they could go on LOA without supervision. Interview on [DATE] at 3:47 P.M. with RN #105 revealed RN #105 was working the night of the elopement. RN #105 confirmed the account of the incident as told by LPN #100 and RN #102. RN #105 reported Resident #94 had exit seeking behavior at times, had impaired decision making, talked about wanting to go to(NAME)to see his father and a times became aggressive. RN #105 was not aware of any protocol for checking the security of the windows. Interview on [DATE] at 5:12 P.M. with corporate nurse, RN #109 revealed there was not a specific protocol for determining when a resident would be assessed for their ability to go on a LOA without supervision. All residents required supervision until a determination was made by a resident's physician that they were safe to leave the facility independently. This was not pursued unless a resident or family expressed an interest in the resident leaving the facility independently. RN #109 indicated because Resident #94 was alert and oriented and his own guardian they did not consider him leaving the facility out a window an elopement but an unauthorized leave. He was alert and oriented and made the decision to exit the facility via a window, this was his choice and his right. Although the decision was poor, unsafe and ultimately resulted in his death, he had the right to make the decision. Unsuccessful attempts were made on [DATE] at 12:31 P.M. and 3:43 P.M. and on [DATE] at 9:50 A.M. and 11:45 A.M. to contact by phone STNA #101 who discovered the open window. Unsuccessful attempts were also made to contact additional staff working the night of the elopement: LPN #122 on [DATE] at 12:36 P.M. and on [DATE] at 9:38 A.M., STNA #123 on [DATE] at 12:50 P.M., STNA #124 on [DATE] at 12:52 P.M., and STNA #125 on [DATE] at 12:54 P.M. Review of the Police Incident Report #,[DATE] dated [DATE] revealed a call of a missing resident was received on [DATE] at 1:53 A.M. An officer arrived at the facility at 2:09 A.M. The resident was reported as very confused at times, not dressed for the weather and had tried to leave the facility before through the locked doors. Dispatch was advised Resident #94 left on foot, in an unknown direction and that he was last seen around the hours of 11:30 P.M., he suffered from [MEDICAL CONDITION], walked with a limp and no one had any idea where he could have gone. Upon the officer's arrival he was met at the door by a nurse who advised him she and her staff had just returned from outside looking for the resident and were unable to locate him. The officer was advised the resident jumped out of his window and no one noticed he had left until they were doing their rounds and found his bedroom window open. Resident #94 was wearing a grey hoodie with red letters, black jeans, a baseball cap and white tennis shoes. He could be very confused at times and the nurse said he was not dressed for the cold weather. The nurse advised the officer Resident #94 had never attempted to leave the facility through his window but had tried to leave through the locked doors in the past. The police searched the surrounding area and were unable to locate Resident #94. Review of the facility's undated description of the incident revealed the police came to the facility on [DATE] at approximately 9:00 A.M. and reported a deceased person fitting the resident's description, wearing a hoodie, jeans and tennis shoes, was found in the yard of a school approximately 1.9 miles east of the facility. The administrator identified the body as Resident #94, at approximately 9:00 A.M. Review of the weather statistics from the National Weather Service website revealed on [DATE] from 12:00 A.M. to 8:53 A.M. the temperatures ranged from -4 Fahrenheit (F) to -16 F with wind chills of -10 F to -27 F. Review of the facility ' s elopement policy dated [DATE] revealed staff were to conduct a headcount when a resident could not be located, contact the Administrator, the DON and the attending physician. If the resident was not located in a reasonable amount of time, based on resident's physical/mental condition and environmental factors, the administrator or designee would notify the local emergency response agencies. This deficiency substantiates Complaint Number OH 431

Based on medical record review, interview with staff and resident guardians, review of the facility Elopement Policy and Leave of Absence (LOA) policy, review of hospital emergency room report, emergency service run report and review of National Weather Forecast records the facility failed to provide adequate supervision to prevent the elopement of Resident #91, who had a court appointed guardian, had a history of [REDACTED]. This resulted in Immediate Jeopardy when facility staff failed to execute a proper search upon finding the resident was missing from the facility. Serious harm and the potential of imminent life threatening danger occurred when Resident #91 was found lying on the ground, incoherent by police who called for emergency medical services to transport the resident to the hospital. This affected one of eight residents assessed as being at risk for elopement. On 09/08/16 at 4:48 P.M., the administrator and director of nursing (DON) were notified that Immediate Jeopardy began on 09/05/16 at 10:00 P.M., when Resident #91 exited the facility unsupervised and the facility failed to implement their elopement policy procedures or notify the local police. The Immediate Jeopardy was removed on 09/09/16 when the facility implemented the following corrective measures: · On 09/08/16 at 5:00 P.M., Regional Nurse #102 began in-servicing staff regarding elopement and leave of absence. Sixty-two staff of the 120 staff was in-serviced. · On 09/08/16, the facility reassessed all residents for elopement risk. Eight residents were identified at risk. There were no additional residents found to be at risk. · On 09/08/16, the facility reviewed care plans for all residents identified at risk for elopement and updated the care plans as needed. · On 09/08/16 at 6:00 P.M., the facility contacted the local police department to report Resident #91 was missing from the facility. · On 09/08/16 at 6:50 P.M., Maintenance Supervisor #103 completed an elopement drill. · On 09/09/16 between 12:05 P.M. and 12:40 P.M., interviews with first shift staff including Licensed Practical Nurses (LPN's) #121 and #122 and State tested Nursing Assistants (STNA's) #120, #123, #124, and #125 revealed they were knowledgeable about the facility ' s procedure for elopement and their role during the process. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility continued to implement corrective measures and all staff had not received in-service training for elopement and leave of absence. Findings include: Review of Resident #91's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Physician History and Physical Exam (H&P) dated 05/04/16 revealed Resident #91 had increased behavioral disturbance due to chronic schizophrenia. The H&P indicated the resident had eloped from his previous facility. Review of physician orders [REDACTED].#91 was ordered medications for schizophrenia including Risperdal Consta 75 milligrams (mg) intramuscularly every 14 days, Risperdal 2 mg daily in the morning, Risperdal 4 mg daily at bedtime, and Seroquel 400mg twice daily. The physician orders [REDACTED]. Review of the facility Elopement assessment dated [DATE] revealed Resident #91 had no history of attempted or actual elopement. Despite having been known to elope from a previous facility Resident #91 was assessed as being not at high risk for elopement. Review of the resident's care plans revealed a care plan initiated on 05/10/16 for supervised leave of absence (LOA) related to mental health [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #91 was cognitively intact, ambulatory with supervision only and displayed no behaviors. Review of guardianship paperwork dated 05/26/16 revealed Resident #91 was deemed by the court incompetent and was adjudicated guardianship of person to extend an indefinite time period. Review of a progress note dated 07/27/16 at 6:59 P.M. written by LPN #106 revealed Resident #91 left the facility unattended in hopes to see his family. The nurse contacted the guardian to explain what happened and to see if the resident could have independent leave of absence (LOA). A progress note dated 07/28/16 at 10:46 A.M. written by Licensed Social Worker #107 revealed she educated Resident #91 on LOA procedures, signing in and out at the nursing station, calling if late returning, and taking all necessary medications. Review of a progress noted dated 07/28/16 at 10:57 A.M. written by LPN #105 revealed Resident #91's guardian did not want the resident to have unsupervised LOA's. Review of an Elopement assessment dated [DATE] revealed Resident #91 had a history of [REDACTED]. Resident #91 was still considered not at risk for elopement. Review of Resident #91's care plans dated 05/05/16 through 08/03/16 revealed they did not include a plan of care for elopement. Review of a progress note dated 09/05/16 at 10:00 P.M. written by LPN #100 revealed Resident #91 was unable to be located. The resident was not found after a search of the facility. The nurse notified the family and guardian. No other action was taken. Review of a witness statement written by STNA #126 on 09/05/16 revealed she last observed Resident #91 after dinner. Review of an undated witness statement written by STNA #127 revealed she observed Resident #91 around 8:30 P.M. Resident #91 requested ice at that time. Review of a witness statement written by STNA #125 on 09/05/16 at 10:50 P.M. revealed he observed Resident #91 at about 10:00 P.M. (09/05/16) when he took another resident out to smoke. No one observed Resident #91 after that time. Review of a Police Incident report dated 09/08/16 at 8:41 A.M. revealed the police received a call of a male laying on the sidewalk and the caller thought the male may need assistance. The police arrived to the area at 8:46 A.M. and contacted 9-1-1 to send an ambulance to transfer the male to the hospital for a psychiatric evaluation. The male was unsure of his name, incoherent and not sure how he got there. Review of the hospital emergency room (ER) record revealed Resident #91 entered the emergency roiagnom on [DATE] at 9:26 A.M. Resident #91 was found lying on the sidewalk and transported by Emergency Medical Services (EMS) to the local hospital. The resident was disoriented and displaying inappropriate speech. He did not know how he got to his location but said he was trying to get home. He was aware of his name but not his address or phone number. Resident #91's laboratory tests indicated he had moderate dehydration and a critically high blood glucose level. His glucose level was 661 ml/deciliter (normal 70 - 100 ml/deciliter). Resident #91 was admitted to the critical care unit with [DIAGNOSES REDACTED]. The ER record indicated Resident #91 was critically ill with a high probability of imminent or life threatening deterioration. On 09/08/16 at 2:30 P.M., an interview with the administrator and DON confirmed they did not implement the elopement policy and procedure when Resident #91 was unable to be located. The administrator indicated they considered Resident #91's leaving the facility as an unapproved LOA. The administrator and DON confirmed Resident #91 had been deemed incompetent by the court system and had a guardian of person. On 09/08/16 at 4:59 P.M., a phone interview with Resident #91's guardian, Guardian #110, revealed Resident #91 eloped in April or May, 2016, just prior to admission to the facility. The guardian was concerned and upset that the facility was not more concerned. The guardian indicated he was not pleased with how the facility handled the situation. On 09/09/16 at 10:36 A.M., a phone interview with Guardian #115 revealed she worked with Guardian #110. She wanted to ensure the surveyor was aware of Resident #91's condition when he was found. Guardian #115 said Resident #91 was found wandering the streets in another city and county from where the nursing home was located. When found, the resident was not wearing shoes and his feet were torn up. He was admitted to the hospital and was currently in the intensive care unit (ICU) for severe dehydration. On 09/09/16 at 11:05 A.M., the administrator confirmed the Physician History and Physical Exam dated 05/04/16 indicated Resident #91 had chronic schizophrenia and eloped from his previous facility. He confirmed the Elopement assessment dated [DATE] indicated Resident #91 had no previous history of attempted or actual elopement or unsafe wandering. On 09/09/16 at 12:34 P.M., an interview with STNA #25 revealed he was the last staff to see Resident #91 on 09/05/16 around 10:00 P.M. He was outside on the patio (secure courtyard) with another smoker. He witnessed Resident #91 go back into the building. STNA #25 said Resident #91 was wearing a tee-shirt with writing/logo but could not remember what the resident had on the lower half of his body or whether he was wearing shoes. Review of the National Weather Service Forecast Office (w2.weather.gov) revealed the following weather conditions on the days Resident #91 was missing. 09/05/16: high 89 degrees Fahrenheit (F)/low 60 degrees F, 9/06/16: high 94 degrees F/low 67 degrees F and trace amount of precipitation, 9/07/16: high 94 degrees F/low 75 degrees F and 0.59 inch precipitation, 9/08/16: high 87 degrees F/low 75 degrees F and 0.25 inch precipitation. Review of the facility's Elopement Policy (revised August 2015) revealed the facility would identify residents with potential and/or actual risk factors for elopement and protect the residents through development and implementation of safety interventions. In the event of a resident elopement the facility would implement it policies and procedures immediately to locate the resident in a timely manner. The elopement procedure included notification of unit charge nurse; after a brief search, and notification of the supervisor in charge. The supervisor would call a Code Green . Staff would conduct an organized search of the building, exterior building and perimeter grounds. If resident was not located, the team leader (highest ranking staff) would notify the family/legal representative that the resident was not on premises. If the resident was not located, the administrator would notify the local police and file a missing person ' s report. Review of the facility LOA Policy (revised September 2009) revealed if a resident did not return to the facility and made no contact with facility with regard to intent to return within 72 hours, the resident would be discharged effective midnight at the end of the third day. This deficiency substantiates Complaint Number OH 796.

Based on staff interview, record review, review of a facility Self Reported Incident (SRI) report and associated investigation, and Abuse policy review, the facility failed to protect residents from abuse after a state tested nurse aide (STNA) #27 admitted to two licensed practical nurses (LPNs) #25 and #29 that she hit a resident with a wet towel while providing care; STNA #27 was allowed to return to work after the facility completed their investigation. This resulted in Immediate Jeopardy when STNA #27 admitted to LPNs #25 and #29 that she hit Resident #82 with a towel. The potential for serious harm continued when STNA #27 was allowed to return to work and provide direct care to residents. This affected Resident #82 and had the potential to affect all 96 residents in the facility. On 08/01/16 at 4:11 P.M., the Administrator, the Director of Nursing (DON) and the Regional Director of Clinical Services were notified that Immediate Jeopardy began on 07/23/16 at 5:50 P.M. when STNA #27 admitted to LPNs #25 and #29 that she hit Resident #82 with a wet towel when the resident was combative during care. The facility suspended STNA #27 on 07/23/16. The facility ' s investigation included written, signed statements by LPN #25 and LPN #29 regarding STNA #27 ' s admission of abuse and Resident #82 ' s allegation that she beat me. The facility concluded that no abuse occurred and found the allegation unsubstantiated. STNA #27 was permitted to return to work and provide direct care to residents on 07/30/16. The Immediate Jeopardy was removed on 08/02/16 at 6:05 P.M. when the facility implemented the following corrective action. · On 08/01/16 and 08/02/16, the DON, Assistant Director of Nursing #2, Minimum Data Set (MDS) Assessment Nurse #3, Dietary Manager #4, Director of Rehab #5 and Director of Environmental Services #6 re-educated three RNs, 12 LPNs, 29 STNAs, two occupational therapists, two occupational therapy assistants, one physical therapist, three physical therapy assistants, two speech therapists, two activity aides, eight dietary aides and nine housekeeping staff on abuse and staff burnout. · On 08/01/16 and 08/02/16, the Admissions Director #7, Dietitian #8, Business Office Manager #9, Director of Rehab #5 and MDS Assessment Nurse #3 conducted 43 interviews of interviewable residents regarding how they were treated by staff. · On 08/01/16 and 08/02/16, the DON, LPN #29, LPN #33, LPN #30, LPN #25, LPN #34 and LPN #35 completed all 94 resident assessments for signs or symptoms of abuse. · Interviews with STNA #36, LPN #37, LPN #33, LPN #34 and LPN #35 on 08/03/16 revealed they had been in-serviced since 08/01/16 regarding staff burnout and resident abuse. Although the Immediate Jeopardy was removed the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility still needed to complete in-servicing regarding abuse and staff burnout for 14 facility staff. Findings include: Medical record review revealed Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #82 had severe cognitive impairment, rejected care during four to six days of the assessment week, and had verbal behavioral symptoms such as screaming and cursing. She was frequently incontinent of bowel and bladder. Review of Resident #82 ' s care plans revealed a plan of care initiated 09/18/15 to address Resident #82 ' s behaviors was in place. Interventions included approach and speak to the resident in a calm manner. Review of the facility ' s SRI report # 6 revealed the following summarized information. LPN #25 and LPN #29 alleged that STNA #27 hit Resident #82 on 07/23/16 at 5:50 P.M. Neither LPN saw STNA #27 hit the resident, but drew their conclusion based on other factors. LPN #25 and LPN #29 indicated they were at the nurses ' station near Resident #82 ' s room when they heard screaming and a noise like somebody being hit with a wet towel or something. LPN #25 said when she and LPN #29 arrived at Resident #82 ' s room, she saw the curtain pulled and a shadow on the door of an arm going up and down with an object in hand. Resident #82 ' s door was open when they approached. LPN #25 and LPN #29 said when they asked STNA #27 what was going on, STNA #27 told them Resident #82 needed to be cleaned up and could not be left like that. STNA #27 said if Resident #82 wanted to fight, they were going to fight. LPN #29 said STNA #27 acknowledged hitting Resident #82 with a towel. STNA #27 denied she hit Resident #82 or that she said they were going to fight, or that she made any such admissions to anyone. Right after the alleged incident was reported on 07/23/16, LPN #28 completed a head to toe assessment of Resident #82 and found no marks or injuries. Resident #82 did not complain of pain, nor did she state to LPN #28 that she had been hit. Resident #82 ' s roommate was not interviewable. STNA #27 had been employed by the facility since March 2016 and there had been no prior allegations or suspicions reported. Staff with any firsthand knowledge of the alleged incident were interviewed. Resident #82 was known to refuse care or to be combative with care. Resident #82 had [DIAGNOSES REDACTED]. The facility concluded the allegation of staff to resident abuse was unsubstantiated for the following reasons. Resident #82 denied the incident. LPN #28 ' s head to toe assessment of Resident #82 revealed no marks or injuries. Resident #82 might have been yelling or screaming as this was something she often did, regardless of the caregiver. LPN #25 and LPN #29 did not know Resident #82 as well as other staff who cared for her regularly. Review of the SRI revealed it included written and signed statements from LPN #25, LPN #28, LPN #29, LPN #30, STNA #27, and STNA #40. Review of LPN #25 ' s written and signed statement dated 07/23/16 revealed that on 07/23/16 at 5:50 P.M., she stood at the nursing cart in front of the nursing station when she heard screaming and a loud noise that sounded like somebody was being hit with a wet towel or something. LPN #25 and LPN #29 then ran down the hall. They stopped at Resident #82 ' s room where they saw the privacy curtain pulled around the resident ' s bed, and a shadow on the door of an arm going up and down with an object in the hand. LPN #25 and LPN #29 went into Resident #82 ' s room and asked what was going on. STNA #27 stated Resident #82 was fighting her while she was cleaning her up. STNA #27 was perspiring and startled. She stated Resident #82 had not been touched all day and she needed to be cleaned and could not be left like that. STNA #27 then stated that if Resident #82 wanted to fight, they were going to fight. LPN #25 then left the room to report the incident to her charge nurse (LPN #30) while LPN #29 stayed in the room with the resident. LPN #25 and LPN #30 returned to Resident #82 ' s room to let STNA #27 know she had to leave the facility due to the allegation of abuse. LPN #30 asked Resident #82 what was going on. Resident #82 stated, She beat me. LPN #25 indicated that Resident #82 appeared to be afraid. LPN #25 observed red marks on Resident #82 ' s chest. LPN #29 stated that Resident #82 did not put the marks on herself. STNA #27 stated, No, I hit her with the towel. Review of LPN #29 ' s written and signed statement (not dated) revealed that on 07/23/16 at 5:50 P.M., she was on the 400 Hall at the nursing station with LPN #25. She heard a resident screaming and a noise as if someone was being struck with a wet object. LPN #29 and LPN #25 went toward the chaos and as they approached Resident #82 ' s room, they could see an arm lift up and down with an object in hand as Resident #82 screamed. They heard STNA #27 yell, Roll over! LPN #29 quickly pulled the privacy curtain back and asked what was going on. STNA #27 stated Resident #82 was soiled and had been that way all day. STNA #27 stated, the resident is fighting me because I ' m cleaning her up, but if she wants to fight, we ' re going to fight. Resident #82 stated she was not fighting STNA #27, that you keep hitting me. Resident #82 looked afraid. LPN #29 asked STNA #27 to step out of the room. LPN #29 stayed with Resident #82 as LPN #25 went to get STNA #27 ' s charge nurse (LPN #30). LPN #25 and LPN #30 returned to Resident #82 ' s room. LPN #30 asked Resident #82 what happened. Resident #82 stated, She beat me! LPN #30 asked Resident #82 who hit her. Resident #82 stated she did not know because she kept her eyes closed. LPN #30 noticed red marks on Resident #82 ' s chest. LPN #29 asked STNA #27 how those marks happened. STNA #27 stated that she and Resident #82 were tussling. LPN #29 stated that Resident #82 did not put those marks on herself, and asked STNA #27 how they got there. STNA #27 stated, No, she didn ' t do it herself. I hit her with the towel. STNA #27 was then told she would have to leave the premises. Review of LPN #30 ' s written and signed statement dated 07/23/16 revealed she was working on the 500 Hall on 07/23/16 when the 100 and 200 Hall nurse, LPN #25, reported they thought that one of the STNAs was popping Resident #82 with a wet towel. LPN #30 then walked over to the 400 Hall to ask the resident what was wrong. Resident #82 stated, She beat me. LPN #30 asked Resident #82 who beat her, and Resident #82 stated she did not know. LPN #30 then went to STNA #27 and told her she had to leave. LPN #30 returned to Resident #82 ' s room with the other nurses. STNA #27 entered Resident #82 ' s room with a dinner tray for her roommate. LPN #29 asked Resident #82 how she got the marks on her. STNA #27 began to explain that Resident #27 was wet and she was trying to clean her up. STNA #27 stated, I pushed her over to clean her and she rolled back over. LPN #29 stated the mark came from somewhere. STNA #27 said something about a towel. LPN #29 then made a statement about how she heard STNA #27 talking loudly to the resident. LPN #29 then repeated what STNA #27 said to Resident #82. STNA #27 stated, Yeah, that ' s what I said. Resident #82 had what appeared to be red scratch marks on the left side of her chest. Resident #82 normally scratched herself, so LPN #30 did not think it was from a hit. Review of LPN #28 ' s written and signed statement dated 07/23/16 revealed LPN #25 approached her while she was getting stock supplies, and reported she had overheard an STNA yelling at Resident #82. LPN #28 entered Resident #82 ' s room and found the STNA standing next to the bed, sweating profusely. LPN #28 did not hear any yelling or find any bruises on Resident #82. LPN #28 then sent the STNA home. Review of STNA #40 ' s written and signed statement dated 07/23/16 revealed she had no knowledge of the incident. She only witnessed the nurses running to Resident #82 ' s room. Review of STNA #27 ' s written and signed statement dated 07/23/16 revealed on 07/23/16 at approximately 4:30 P.M., she started her resident rounds. She smelled bowel on the 400 Hall and found the odor was coming from two rooms, one of which was Resident #82 ' s room. STNA #27 gathered her supplies and discovered a pile of bowel on the toilet seat and on the back of the toilet in Resident #82 ' s bathroom. STNA #27 wrote that Resident #82 could have been injured when she went into the bathroom unassisted, but STNA #27 stated her body was intact. STNA #27 then found Resident #82 with feces from head to toe, wearing a soaking wet diaper and depends. STNA #27 wrote that she worked with Resident #82 regularly, and the resident was sometimes very combative. On 07/23/16, she gave personal care to Resident #82 with the door wide open and the curtain closed. Resident #82 ' s room was a foot away from the nursing station, where STNA #27 ' s supervisor, LPN #28 stood with STNA #40. STNA #27 reported to LPN #28 that Resident #82 was giving her a hard time, and that was not the first time it had happened. STNA #27 stated she always told her nurse when Resident #82 gave her a hard time, but she never got any help until that day. It was very hot, and STNA #27 was sweating and was tired from trying to clean Resident #82 and change the bed. STNA #27 asked STNA #42 for help in dressing Resident #82. STNA #27 then saw LPN #25 and LPN #29 at the nursing station. They asked her what was all the noise? STNA #27 explained and kept working. She finished with Resident #82 and passed trays for about 20 minutes. STNA #27 entered Resident #82 ' s room with her dinner tray. LPN #25, LPN #29 and LPN #30 were in Resident #82 ' s room. STNA #27 heard LPN #30 ask Resident #82 if anyone hit her. Resident #82 said no, she did not have any problems with anyone. LPN #29 continued to ask Resident #82 if anyone had hit her. Resident #82 then said that somebody hit her, but she did not know who. STNA #27 wrote that Resident #82 said that someone hit her, but never accused STNA #27. STNA #27 wrote that LPN #29 asked the question so much that it was as if she wanted Resident #82 to say it. STNA #27 left the room and continued to pass trays on the unit. STNA #27 ' s nurse then told her to leave the facility. STNA #27 indicated they made a big deal out of a misunderstanding. STNA #27 left the building. She wrote that Resident #82 sometimes was a very confused woman. She sometimes screamed things like, Nurse, nurse, she ' s killing me, she ' s touching my lady parts, call the police, nurse, nurse, she won ' t leave me alone, nurse, nurse, help, help! STNA #27 wrote that Resident #82 said those things when no one was doing anything to her. Interview with LPN #25 on 08/01/16 at 12:05 P.M. revealed on 07/23/16, she was at the nursing station on the 400 Unit when she heard a resident screaming. She stated she ran to Resident #82 ' s room and found the resident lying naked in bed with her arms folded across her chest. STNA #27 stood next to Resident #82 ' s bed and was perspiring and breathing heavily. She held a wet towel in her hand. STNA #27 told LPN #25 that if Resident #82 wanted to fight, they were going to fight. Resident #82 stated, She beat me! She beat me! LPN #25 observed a red mark on Resident #82 ' s chest. STNA #27 stated she had hit Resident #82 with a towel. LPN #25 stated that LPN #29 and LPN #30 also were present in Resident #82 ' s room after the incident occurred when STNA #27 admitted that she had struck Resident #82 with a wet towel. Interview with LPN #30 on 08/01/16 at 12:35 P.M. revealed LPN #25 and LPN #29 were present when she arrived in Resident #82 ' s room after she was informed of the incident on 07/23/16. She stated STNA #27 had already been sent home and was no longer present in Resident #82 ' s room. Resident #82 was dressed in a gown that was loosely draped across her upper body and exposed the upper part of her chest. LPN #30 stated she saw a red area on Resident #82 ' s chest. She stated she did not know how Resident #82 sustained a red mark and indicated the resident may have scratched herself. Interview with LPN #28 on 08/01/16 at 1:30 P.M. revealed she worked on the 300 Hall on 07/23/16 and did not hear or see anything involving an incident with Resident #82. She stated she was very busy passing medications. It was dinner time and it was very busy in the facility. STNA #25 approached her and they went to Resident #82 ' s room. LPN #28 saw STNA #27 standing over Resident #82. STNA #27 was sweating but it was hot. STNA #27 did not hold any object in her hands. Resident #82 was awake and dressed in a clean gown. LPN #28 asked Resident #82 what happened, but Resident #82 did not remember anything. She was very confused. LPN #28 completed a head to toe assessment on Resident #82 and did not find any bruises, marks or anything. LPN #28 informed STNA #27 that she would have to leave the facility. STNA #27 asked her why, but LPN #28 did not tell her. An interview with the Administrator on 08/01/16 at 2:05 P.M. revealed he believed there was no conclusive evidence to support that STNA #27 abused Resident #82. He stated he believed the statements made by LPN #25 and LPN #29 were based upon their perception of events. The administrator indicated that because the alleged incident was not actually observed by any staff, the events were open to interpretation and therefore, he could not conclude that abuse occurred. The Administrator indicated STNA #27 was suspended during the investigation but was permitted to return to work on 07/30/16 after the facility determined the allegation was not substantiated. Interview with STNA #27 on 08/01/16 at 4:32 P.M. revealed she has worked in this facility since 03/30/16. She stated on 07/23/16, about one and one half hours after she started her shift, she found Resident #82 lying in her bed, wrapped up in a blanket. Under the blanket, Resident #82 was covered in feces from head to toe. There was feces in the bathroom. No one had changed her since morning. Resident #82 was combative and did not want to be touched. LPN #28 and STNA #40 were at the nursing station. STNA #27 told LPN #28 that Resident #82 was giving her a hard time. LPN #28 stated, Yeah, I know how she is. STNA #27 stated she could not leave Resident #82 in the condition she was in. STNA #42 was with another resident. LPN #29 and LPN #25 were at the nursing station on the 400 Hall. They asked STNA #27, What ' s all that noise? STNA #27 told them that it was Resident #82, and that was it, she continued to do her job. STNA #42 helped her. STNA #27 then gave Resident #82 her tray. LPN #25, LPN #29 and LPN #30 were in Resident #82 ' s room. They asked Resident #82 if anyone was hitting her or messing with her. Resident #82 said no. STNA #27 left the resident ' s room and passed more trays to residents. LPN #30 then came to her and told her to go home due to the complaints related to hitting Resident #82. During the daily meeting with the facility on 08/02/16 at 4:30 P.M., the facility ' s Corporate Regional Vice President confirmed the facility ' s investigation did not include a statement from STNA #42. On 08/03/16 at 8:20 A.M., the Administrator presented a statement attributed to STNA #42 that was dated 08/02/16. The statement was not signed by STNA #42 but was initialed by the administrator. According to this information, STNA #42 indicated she helped STNA #27 dress Resident #82 and that STNA #27 did not hit Resident #82. Review of the facility Abuse policy and procedure (revised May 2016) revealed witnesses to abuse included anyone who witnessed or heard the incident as well as employees who worked closely with the accused employee or alleged victim the day of the incident. This deficiency substantiates Control Number OH 877.