Every finding on record at Wooded Glen

Based on observation, policy review, and staff interview, the facility failed to ensure expired intravenous (IV) solution was removed from medication storage in accordance with a pharmacy label or manufacture's expiration date. This had the potential to affect one resident (#239) who the facility identified as receiving IV solution. The facility census was 51. Findings include:Observation on [DATE] at 1:12 P.M. of the IV cart on 400-hall with the Director of Nursing (DON) revealed Dextrose 5% and sodium chloride 9% 1,000 milliliter (ml) with do not use beyond date of [DATE], Lactated Ringers 1,000 ml with do not use beyond date of [DATE], 5% Dextrose 250 ml expiration of [DATE], 0.9% Sodium Chloride 50 ml with expiration of 12/2024, three bags 5% Dextrose 100 milligrams (mg) with expiration of 02/2025, 5% Dextrose 100 ml with do not use beyond date of 11/20244, 10% Dextrose 1,000 ml expiration of 03/2025, Lactated Ringers 1,000 ml expiration date of 05/2025, and Lactated Ringers and 5% Dextrose 1,000 ml expiration date of 12/2024. Interview on [DATE] at 1:12 P.M. with the DON revealed she assumed the pharmacy representative was reviewing and removing expired IV solutions. The DON verified there were twelve IV solution bags that were expired in the IV cart. The facility identified one resident (#239) who was receiving IV solution during the survey. Review of the facility policy titled Medication Storage dated [DATE] revealed outdated medications must be immediately pulled from active inventory and segregated to an area to prevent unintentional use. This deficiency represents non-compliance investigated under Complaint Number 2612621.

Based on record review, staff interviews, and policy review, the facility failed to ensure fall prevention interventions were utilized in accordance with physician orders. This affected one (#50) out of three residents reviewed for falls. The facility census was 49. Findings include: Review of the closed medical record for Resident #50 revealed an admission date of 04/01/25 and a discharge date of 05/04/25. Diagnoses included encephalopathy, acute respiratory failure with hypoxia, congestive heart failure, acute kidney failure, and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) assessment, dated 04/07/25, revealed Resident #50 had severely impaired cognition. Resident #50 was assessed to require supervision for eating, oral hygiene, and personal hygiene, substantial/maximal assistance for toileting, bathing, lower body dressing, and partial/moderate assistance for upper body dressing, bed mobility, and transfer. Review of the plan of care initiated on 04/14/25 revealed Resident #50 was at risk for falling related to chronic obstructive pulmonary disease. Interventions included encourage resident to assume standing position slowly, ensure the floor is free of liquids and foreign objects, keep call light, personal items, and frequently used items within reach, provide non-skid footwear, and assist with transfers as needed. Review of the progress note dated 04/28/25 at 1:40 A.M. revealed Resident #50 was found on the floor on his back with no clothes or shoes on and had his hands under his head. His head was pointed towards the door and his legs were towards the bed. Resident #50 was assessed and noted to have a small abrasion to the right side of his right foot, which was cleaned and covered with a dressing. Review of the progress note dated 04/28/25 at 2:20 A.M. revealed new interventions implemented were bed in lowest position and mat next to bed. Review of the progress note dated 04/28/25 at 10:49 P.M. revealed Resident #50 had a fall in his room. The note indicated a new intervention was mat next to bed. Review of the physician orders revealed an order was entered 04/28/25 at 10:52 P.M. for fall mats on both sides of the bed and bed in lowest position. Review of the progress note dated 04/28/25 at 11:22 P.M. revealed Resident #50 was lying on the floor on the right side of his bed. Resident #50 was assessed and observed to have a skin tear to his right shin. Fall mats were placed on both sides of his bed and the bed was in the lowest position. Interview on 06/04/25 at 10:50 A.M. with Licensed Practical Nurse (LPN) #70 revealed no fall mats were on the floor when Resident #50 was found on the floor on the evening of 04/28/25. LPN #70 stated the new intervention added were floor mats. Interview on 06/04/25 at 1:32 P.M. with the Director of Nursing (DON) verified floor mats were documented as the new intervention following Resident #50's fall in the morning on 04/28/25 and then again after the fall in the evening on 04/28/25. Review of the facility policy titled Fall Management Program Guidelines, reviewed 03/16/22, revealed the resident care plan should be updated to reflect any new or change in interventions, and staff should communicate interventions during shift report. This deficiency represents non-compliance investigated under Complaint Number OH00165557.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to follow proper infection control practices during medication administration. This affected one (Resident #25) of the three residents reviewed for medication administration. The facility census was 50 residents. Findings include: Review of the medical record for Resident #25 revealed an admitted [DATE] with diagnoses of sepsis, clostridium difficile, colitis, hypertensive heart disease, and congestive heart failure. Review of the admission Minimum Data Set (MDS) assessment for Resident #25 dated 07/22/24 revealed the resident was cognitively intact and required staff assistance with activities of daily living. Review of the physician's orders for Resident #25 revealed an order dated 08/12/24 for hydralazine 10 milligram (mg) one tablet by mouth four times per day. Observation on 08/15/24 at 8:12 A.M. revealed Registered Nurse (RN) #208 prepared Resident #25's medications for administration. RN #208 dropped Resident #25's hydralazine 10 mg tablet on the top of the medication cart, picked the tablet up with her bare hands and placed the tablet into the pill cup. RN #208 administered medications from the pill cup to Resident #25 which included the hydralazine tablet. RN #208 did not perform hand hygiene at any time during the observation. Interview on 08/15/24 at 8:20 A.M. with RN #208 confirmed she touched Resident #25's hydralazine tablet with her bare hands and then administered the medication to the resident. RN #208 further confirmed she had not performed hand hygiene prior to, during, or after medication administration to Resident #25. Review of the facility policy titled Medication Administration revised November 2018 revealed hand hygiene should be performed before beginning of med pass, prior to handling any medications, after coming into direct contract with a resident, and before and after gastroenteric tube medication administration. Policy stated staff are to perform appropriate hand hygiene prior to handling tablets and examination gloves must be worn to prevent touching of tablets during the process.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed ensure proper labeling of insulin vials. This affected one (Resident #33) resident of three reviewed for medication administration. The facility census was 50 residents. Findings include: Review of the medical record for Resident #33 revealed an admitted [DATE] with medical diagnoses including pancreatitis, diabetes mellitus, disorder of the thyroid, osteoarthritis, and asthma. Review of the admission Minimum Data Set (MDS) assessment for Resident #33 dated [DATE] revealed the resident had moderate cognitive impairment and required supervision and staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #33 revealed an order dated [DATE] for Humalog (insulin) inject 15 units subcutaneously three times per day. Observation on [DATE] at 7:56 A.M. revealed Licensed Practical Nurse (LPN) #209 prepared the Humalog injection for Resident #33. Neither the box containing the vial of insulin nor the vial itself were dated upon opening. LPN #209 drew up 15 units of Humalog and subcutaneously injected the insulin into Resident #33's right upper arm. Interview on [DATE] at 8:04 A.M. with LPN #209 confirmed Resident #33's insulin had not been dated upon opening and she was unsure if it had expired or not. LPN #209 further confirmed insulin should be dated upon opening. Review of the facility policy titled Medication Storage revised [DATE] revealed medications and biologicals should be stored safely, securely, following manufacturer's recommendations or those of the supplier. Multiple dose injectable vials, once opened, need an expiration date shorter than the manufacturer's expiration date to insure medication's purity and potency. When the original seal of a manufacturer's container or vial that requires a shorter expiration is initially broken, the vial should be dated with a dated. A date opened sticker should be placed on these mediations and nurses should check the expiration date of each medication before administering it. No expired mediations should be administered to the resident.

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected two (Residents #40 and #197) of eight residents reviewed for medications administration. The facility census was 50. Findings include: 1. Review of the medical record for Resident #197 revealed an admitted [DATE] with diagnoses including orthostatic hypotension, methicillin-resistant staphylococcus aureus (MRSA) bacteremia, persistent postprocedural fistula, and chronic obstructive pulmonary disease (COPD). Review of the admission assessment for Resident #197 dated 06/08/24 revealed the resident was cognitively intact, had a current infection, and received an intravenous (IV) medication. Review of the hospital discharge summary for Resident #197 dated 06/08/24 revealed an order for daptomycin (an antibiotic) IV 940 milligrams (mg) daily for six weeks. Review of the June 2024 monthly physician orders for Resident #197 revealed a physician order dated 06/10/24 for daptomycin 940 mg IV daily. Review of the Medication Administration Record (MAR) for Resident #197 dated June 2024 revealed daptomycin IV was administered as ordered starting on 06/10/24. The medication was not administered on 06/08/24 or 06/09/24. Interview on 06/10/24 at 10:09 A.M. with Resident #197 confirmed he admitted to the facility on [DATE] and was supposed to receive IV medication daily for an infection, but he hadn't received any medication through his peripherally inserted central catheter (PICC) since he left the hospital. Interview on 06/12/24 at 9:33 A.M. with DON confirmed the hospital discharge summary dated 06/08/24 included an order for daptomycin 940 mg IV daily. The DON confirmed the facility did not order or administer the medication until 06/10/24 which was an error of omission for daptomycin on 06/08/24 and 06/09/24. Interview on 06/12/24 at 9:37 A.M. with Licensed Practical Nurse (LPN) #127 confirmed she was notified per verbal report from night shift nurse on the morning of 06/10/24 that Resident #197 was supposed to receive an IV antibiotic but did not see an order for the medication. LPN #127 stated she reviewed Resident #197's medical record and saw the order for daptomycin in the hospital discharge summary, entered the ordered into the electronic medical record, and ordered the medication from the pharmacy. LPN #127 confirmed she administered the daptomycin 940 mg IV to Resident #197 via PICC line on 06/10/24 as ordered. 2. Review of the medical record for Resident #04 revealed an admitted [DATE] with diagnoses including hypertensive heart disease, congestive heart failure, chronic respiratory failure, COPD, and diabetes mellitus. Review of the annual Minimum Data Set (MDS) assessment for Resident #04 dated 03/06/24 revealed the resident was cognitively intact and required staff assistance with bathing and toilet hygiene and supervision with bed mobility and transfers. Review of the progress note for Resident #04 dated 12/07/23 timed at 3:04 P.M. per the nurse practitioner (NP) revealed Aldactone (a diuretic medication) should be discontinued due to hyperkalemia (a high level of potassium in the blood.). Review of the pharmacy recommendation for Resident #04 dated 12/15/24 revealed the NP progress note dated 12/07/24 stated the Aldactone should be discontinued but the resident was still receiving the medication. The pharmacy recommendation was for staff to clarify the order. Review of the physician's orders for Resident #04 revealed an order dated 12/20/24 to discontinue Aldactone. physician order dated 09/23/23 for Aldactone 25 milligram (mg) by mouth one tab daily. Review of a physician order dated 12/20/23 revealed the Aldactone was discontinued. Review of the MAR for Resident #04 dated December 2023 revealed the received Aldactone by mouth daily until 12/20/24. Interview on 06/13/24 at 9:15 A.M. with the Director of Nursing (DON) confirmed the NP intended for the staff to discontinue Resident #04's Aldactone on 12/07/24, but it was not discontinued until 12/20/24. The medication was administered in error from 12/07/24 to 12/20/24. Review of the facility policy titled Medication Administration revised November 2018 revealed medications were to be administered in accordance with the written orders of the prescriber.

Based on medical record review, observation, staff interview, review of facility policy, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to have staff members wear appropriate personal protective equipment (PPE) when caring for residents in quarantine for potential exposure to Coronavirus Disease 2019 (COVID-19). This affected one (#17) of three residents reviewed for infection control. The census was 44. Findings include: Review of Resident #17's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A comprehensive Minimum Data Set (MDS) assessment was not yet completed. Further review revealed Resident #17 was not vaccinated for COVID-19. Review of Resident #17's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #17 is to stay in room entire stay with no roommate. All therapy, meals, activities, and services will be provided in the room. Observation on 08/24/22 at 12:04 P.M. revealed State tested Nursing Assistant (STNA) #76 and STNA #92 enter Resident #17's room with a Hoyer (mechanical lift). Neither STNA #76 or STNA #92 put on any, gown or a N95 respirator mask. STNA #76 and STNA #92 were wearing surgical masks and eye protection. Observation of Resident #17 room entrance revealed signs to the right of the door with information about PPE use and a sign yellow zone. PPE listed for use was a gown, gloves, eye protection (faceshield or goggles), and N95 respirator mask. A receptacle containing faceshield's, N95 respirator masks, gowns, and gloves was present at the entrance to Resident #17's room. During an interview on 08/24/22 at 12:08 P.M. with STNA #76 and STNA #92 both confirmed they had entered Resident #17's room to provide care and had not donned a gown or N95 respirator mask. STNA #76 and STNA #92 confirmed Resident #17 was in contact/droplet precaution in the yellow zone. Observation on 08/24/22 at 12:09 P.M. revealed Registered Nurse (RN) #104 donning PPE to enter Resident #17's room. RN #104 put on a gown, gloves, then put a N95 respirator mask over a surgical mask she was already wearing. RN #104 then entered Resident #104's room and talked to her about an upcoming appointment. During an interview on 08/24/22 at 12:11 P.M. RN #104 confirmed she had covered her surgical mask with an N95 respiratory mask before entering Resident #17's room. RN #104 was not aware of any concern with using a surgical mask under a N95 respirator mask. During an interview with the Director of Nursing (DON) and Clinical Support (CS) #130 on 08/24/22 at 12:20 P.M. both confirmed that staff are to wear a N95 respiratory facemask, eye protection, gloves, and a gown when caring for residents in quarantine for COVID-19 precautions or yellow zones and they confirmed Resident #17 is currently in quarantine for COVID-19 precautions. Both confirmed surgical masks should not be worn under a N95 respirator mask. Review of the facility's policy COVID-19 Guideline for PPE dated as revised 10/20/21 revealed when caring for residents in yellow zones staff must wear a N95 respirator mask, eye protection, a gown, and gloves. Review of the CDC guidance titled How to Use Your N95 Respirator dated 03/16/22 revealed a N95 must seal to your face to work properly. This deficiency substantiates Complaint Number OH 940.

Based on record review and interview, the facility failed to ensure a resident's representative was notified of a significant change in treatment in the addition of an new anti-psychotic medication to treat adverse behaviors. This affected one (Resident #42) of four residents reviewed for new medications. The census was 41. Findings include: Review of the medical record for Resident #42 revealed an admitted [DATE] and discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment dated [DATE] revealed the resident was moderately cognitively impaired. Review of the baseline plan of care for Resident #42 revealed a plan for resident will be free from adverse effects on necessary medications administer medications per doctor order, observe side effects of medications and notify doctor if any noted and maintain resident on lowest therapeutic dose. Review of progress notes dated 09/15/21 at 3:50 P.M. revealed the resident alert with much confusion. The resident was calling out into hall multiple times throughout shift despite much redirection one to one, change of position, incontinent care and feeding. The Nurse Practitioner (NP) in to see resident. New orders received to start [MEDICATION(S)] 25 mg per day. The medication administered with no noted change. The NP then ordered [MEDICATION(S)] 25 mg twice a day and may increase if noted without change up to 75 mg total and [MEDICATION(S)] 5 mg by mouth twice a day. The resident denies complaints of pain and was restless. The resident continued to yell, despite assisting resident into bed per request. Resident transfer status changed to Hoyer lift for safety due to resident not bearing weight with transfers and inability to follow directions and commands. Resident currently resting in bed, restless with eyes closed and yelling into hall. Bed in lowest position with call light in reach. Will monitor. The progress note contained no documentation the resident's representative was notified of the change in treatment, behaviors and addition of the anti-psychotic medications. During interview on 10/13/2021 at 2:45 P.M., the Director of Health Services verified there was no documentation the resident's representative was notified of the behaviors or the addition of the anti-psychotic medications. This deficiency substantiates Complaint Number OH 147.

Based on observations, staff interviews, and policy review, the facility failed to practice safe food handling to prevent contamination. This had the potential to affect all 32 residents who receive food from the kitchen (Resident #13 receives nothing by mouth). The census was 33. Findings Include: Observation on 08/16/21 at 11:19 A.M., revealed a red bucket of cleaning water on the prep table. Beside the red bucket were two large uncovered five pound tubs of mushrooms and tomatoes. Observation of the serving line on 08/16/21 at 11:45 A.M., revealed Dietary Worker #48 placed plated pie on a serving cart with a gloved hand. When the piece of pie was placed on the cart it moved off the plate and Dietary Worker #48 used the same gloved hand to place the pie back onto the plate. Dietary Worker #48 proceeded to continue plating more pie with the same gloved hand until the state surveyor intervened. Interview with Dietary Worker #48 at the time of the observation confirmed she touched the pie with her gloves and proceeded to continue plating more pie without changing her gloves. Observation on 08/16/21 at 12:40 PM, revealed Dietary Worker #45 was carrying two pieces of bread and cheese to the prep table and placed it directly onto the table. The sandwich was not placed on a plate or wrapped in plastic wrap. She walked across the kitchen to the dish washing area to retrieve the food processor. When she returned, she proceeded to pick up the bread and cheese with the same gloved hands. These observations were made with Dietary Manager #41. Review of the facility policy titled Single-Use Gloves, dated 11/22/17, revealed an employee must wash hands before putting on gloves and after discarding gloves. Change gloves when ever an activity or workstation change occurs, or whenever they become contaminated.

Based on medical record review, observation, staff interview, review of State-tested Nurse (STNA) care sheet, and review of facility policy, the facility failed to ensure Resident #27 was appropriately transferred with the correct mechanical lift and with the correct amount of staff assistance in accordance with physician orders. This affected one (#27) out of three residents reviewed for falls. The facility's census was 29. Findings included: Medical record review for Resident #27 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #27's most recent Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was a eight out of 15, indicating Resident #27 was cognitively impaired. Resident #27 required extensive assistance from two staff for transfers. Review of Resident #27's physician orders [REDACTED].#27 was to be transferred by two staff using a Hoyer lift at all times for safety. Observation on 03/18/21 at 9:48 A.M. revealed Resident #27 was being transferred from his wheelchair to his bed by State tested Nurse Aide (STNA) #555 utilizing a sit to stand lift. There were no other staff members present during the observation. Resident #27 was sitting on his bed holding onto the sit to stand lift's handles, while STNA #555 was unfastening Resident #27 from the lift. STNA #555 struggled with the transfer on her own and at one point instructed Resident #27 to hold onto a cabinet's handle (located next to the bed) to hold himself up. STNA #555 instructed Resident #27 to let go of the lift's handles. When Resident #27 let go of the lift's handles, he fell backwards, landing sideways onto his bed and almost hitting his head on the corner of the bed side table. STNA #555 then repositioned Resident #27 into bed properly. Interview on 03/18/21 at 11:45 A.M. STNA #555 verified she was the only staff member transferring Resident #27 and she utilized a sit to stand lift. STNA #555 reported Resident #27 was transferred using a sit to stand lift, sara steady lift, or Hoyer lift. STNA #555 reported if she used the Hoyer lift, she would have had another staff members assistance. STNA #555 stated Resident #27 was typically able to help with his transfers, but he was not able to do so during the transfer observed. STNA #555 reported she should have asked another staff member to help her with Resident #27's transfer and admitted she struggled with the transfer. Further interview with STNA #555 verified she used the wrong lift when transferring Resident #27. STNA #555 reported she should have used a Hoyer lift with a second staff person's assistance. STNA #555 reported she forgot to review the STNA care sheet and realized Resident #27 had changed to a Hoyer lift with two staff assistance. Interview on 03/18/21 at 12:01 P.M. Licensed Practical Nurse #566 verified Resident #27 had a physician order [REDACTED].#566 reported Resident #27 was assessed. LPN #566 reported she spoke with therapy and Resident #27 will be assessed for transfers. Interview on 03/18/21 at 1:05 P.M. the Director of Nursing (DON) reported STNA #555 reported she used the wrong lift and did not have assistance when transferring Resident #27. The DON reported staff have been educated. Review of STNA care sheet updated 03/18/21 revealed Resident #27 required a Hoyer and assistance from two staff for transfers. Review of facility policy titled, Guidelines for Resident Utilizing Lift, approved 05/11/17 revealed the facility would ensure residents and staff were safe when performing lift transfer tasks. Staff should seek the assistance of a second staff person for residents who required assistance from two staff. Review of facility policy titled, Guidelines for Resident Transfers and Assistance, effective 05/10/17 revealed staff should seek the assistance of a second staff person for residents who required assistance from two staff. Review of facility policy titled, Fall Management Program Guidelines, effective 05/31/17 revealed the facility would strive to maintain a hazard free environment. This deficiency substantiates Complaint Number OH 435.

Based on observation, staff interview, review of manufacturer's recommendations, and policy review, the facility failed to ensure medications were dated upon opening and removed from use when expired. This affected two (100 Hall and 200 Hall) of two medication carts reviewed and two (100/200 Hall and 400 Hall) of two medication rooms. The facility census was 43. Findings include: 1. Observation of the 200 Hall medication cart with Licensed Practical Nurse (LPN) #10 on 03/07/19 from 1:35 P.M. until 1:45 P.M. revealed there was an opened and undated bottle of [MEDICATION NAME] 0.15% eye drops, a bottle of [MEDICATION NAME] 0.01% eye drops that were opened and undated, and an opened and undated [MEDICATION NAME] Respimat 1.25 mcg/actuation inhaler. Additionally, there was a bottle of olopatadine [MEDICATION NAME] 0.2% eye drops that was opened and undated. Furthermore, there was an opened bottle of Humalog 100 units/milliliter vial that contained an opened date of 01/31/19. Review of the manufacturer's recommendations for Humalog revealed to discard opened vials within 28 days. Interview with LPN #10 on 03/07/19 at 1:46 P.M. confirmed the above medications which were opened and undated and confirmed the Humalog was expired. 2. Observation of the 100/200 Hall medication storage room with LPN #10 on 03/07/19 at 1:47 P.M. revealed there were three bottles of [MEDICATION NAME] Purified Protein Deriative, that were opened and undated. Review of the manufacturer's recommendations for [MEDICATION NAME] Purified Protein Derivative revealed to discard opened vials within 30 days. Interview with LPN #10 on 03/07/19 at 1:49 P.M. confirmed the [MEDICATION NAME] Purified Protein Derivative was opened and undated. 3. Observation of the 100 Hall medication cart with LPN #10 on 03/07/19 from 1:55 P.M. until 2:01 P.M. revealed an opened and undated bottle of Brigandine 0.2% eye drops, an opened and undated bottle of dorzolamide-[MEDICATION NAME] 22.3-6.8 milligram/ml eye drops, an opened and undated bottle of Latanoprost 0.005% eye drops. Additionally, there was a tube of [MEDICATION NAME] ointment 0.5% that was opened and undated, a bottle of [MEDICATION NAME] 0.01% eye drops that were opened and undated and a bottle of [MEDICATION NAME] 0.5% eye drops that were opened and undated. Interview with LPN #10 on 03/07/19 at 2:02 P.M. confirmed the above medications were opened and undated. 4. Observation of the 400 Hall medication room with LPN #47 on 03/07/19 at 2:10 P.M. revealed a vial of [MEDICATION NAME] 0.5 milliliters (ml) that had an expiration date of 02/16/19. Interview with LPN #47 at the time of the observation confirmed the [MEDICATION NAME] was expired. Review of the facility policy titled Medication Storage in the Facility, dated 11/18, revealed certain medications or package types such a ophthalmic's and multiple dose injectable vials require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. It indicated when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. A date opened sticker shall be placed on the medication. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating. The medication administration personnel will check the expiration date of each medication before administering it. It revealed that all expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining.

Based on observations, record review, staff interview, and review of the facility policy, the facility failed to ensure gloves were worn during the administration of eye drops. This affected two (#32 and #90) residents observed during medication administration. Additionally, the facility failed to ensure the glucometer was sanitized between two residents. This affected two (#7 and #34) of seven residents who required blood sugar checks. The facility also failed to ensure hand hygiene was performed, sanitization was completed with the use of a dinamap, and that a resident was in contact precautions per physician orders. This affected one (#28) of two residents reviewed for infections. The facility census was 43. Findings include: 1. Observations of medication administration on 03/05/19 from 9:09 A.M. until 9:14 A.M. with Licensed Practical Nurse (LPN) #47, revealed she prepared Resident #32's medications including [MEDICATION NAME] (eye drop for chronic dry eyes) 0.05%. On 03/05/19 at 9:14 A.M., LPN #47 was observed to administer Resident #32 his [MEDICATION NAME] 0.05% eye drops one drop to both eyes without wearing gloves. 2. Observations of the medication administration on 03/05/19 from 9:18 A.M. until 9:32 A.M. with LPN #47, revealed she prepared Resident #90's medications. These medications included [MEDICATION NAME] (blood pressure medication) 10 milligram (mg) one tablet, Aspirin 81 mg one tablet, [MEDICATION NAME] plus D3 (vitamin) 250/500 mg one gummie, Vitamin B 12 1000 micrograms (mcg) one tablet, [MEDICATION NAME] (stool softener) 100 mg one tablet, [MEDICATION NAME] (iron) 325 mg one tablet, Folic Acid 1 mg one tablet, K-Phos-Neutral 250 mg one tablet, Magnesium Oxide 400 mg 0.5 tablet to equal 200 mg, [MEDICATION NAME] (blood pressure medication) 50 mg one tablet, [MEDICATION NAME] (medication for [MEDICAL CONDITION] reflux disease GERD) 40 mg one tablet, [MEDICATION NAME] (steroid) 10 mg one tablet, Senna (medication for constipation) 8.6 mg two tablets, [MEDICATION NAME] (medication for nerve pain) 50 mg one tablet, [MEDICATION NAME] (pain medication) 50 mg one tablet and [MEDICATION NAME] 0.4-0.3% eye drops. During this observation, LPN #47 was observed to pop the [MEDICATION NAME] 325 mg out of the medication package and the medication landed on the medication cart. LPN #47 picked the pill up with her bare hands off of the medication cart and placed the pill inside the medication cup. While preparing the medications, LPN #47 was observed to pop the Senna 8.6 mg two tablets, and the [MEDICATION NAME] 50 mg one tablet from the medication package into her bare hands, and then she placed the medications into the medication cup. On 03/05/19 at 9:31 A.M., LPN #47 was observed to administer Resident #90's [MEDICATION NAME] 0.4-0.3% eye drops, one drop to both eyes. LPN #47 was not observed to wear gloves during administration of the eye drops. Interview with LPN #47 on 03/05/19 at 9:37 A.M., confirmed she did not wear gloves for Resident #32 or Resident #90, while administering their eye drops and verified she should have. LPN #47 confirmed she popped the pills out into her bare hand and then placed the pills into the medication cup for administration. She verified she should not have touched the pills and should have popped them into the medication cup. Additionally, she confirmed she dropped Resident #90's [MEDICATION NAME] on top of the medication cart, picked the pill up with her bare hands and placed the medication into the medication cup for administration. LPN #47 confirmed she should have disposed of the medication and replaced them. 3. Observations on 03/05/19 at 12:02 P.M., revealed LPN #10 checked Resident #7's blood sugar. LPN #10 then returned to the medication cart and cleansed the glucometer with an alcohol pad. LPN #10 was not observed to properly sanitize the glucometer before or after use. Observations on 03/05/19 at 12:19 P.M., revealed LPN #10 checked Resident #34's blood sugar using the same glucometer she used with Resident #7. After obtaining Resident #34's blood sugar, she returned to the medication cart and cleansed the glucometer with an alcohol pad. LPN #10 was not observed to properly sanitize the glucometer before or after use. Interview with LPN #10 on 03/05/19 at 12:22 P.M., confirmed she cleansed the glucometer with an alcohol pad between Resident #7 and Resident #34. She verified she typically uses bleach wipes, however, she didn't have any on her cart and used the alcohol pads. 4. Review of Resident #28's record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the admission minimum data set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) should be conducted, however, Resident #28's BIMS was not assessed. It identified the resident as requiring an extensive two person assist with bed mobility; extensive two person assist with transfers; limited one person assist with dressing; supervision set up assist with eating; extensive one person assist with toilet use and limited one person assist with personal hygiene. Review of Resident #28's physician orders revealed an order initiated on 01/23/19 for contact precautions [MEDICAL CONDITION] in the wound three times a day. Review of the (MONTH) 2019 treatment administration record, revealed staff were signing off on the treatment every shift indicating Resident #28 was in contact precautions [MEDICAL CONDITION] in the wound. Interview with LPN #10 on 03/04/19 at 10:50 A.M., revealed Resident #28 was no longer in isolation. She verified the residents wound was covered; so unless staff were touching the wound, no personal protective equipment (PPE) needed to be worn. Observation on 03/04/19 at 10:50 A.M., revealed there was an isolation cart located inside of the residents room. However, there was no sign located on the outside of the residents room to identify the resident being in contact precautions. Observation on 03/04/19 at 3:29 P.M., revealed LPN #63 entered Resident #28's room without gloves and without any other PPE. LPN #63 was observed to obtain the residents vital signs using a dinamap blood pressure machine (portable blood pressure monitor). LPN #63 then exited Resident #28's room without washing or sanitizing her hands nor sanitizing the dinamap. She then entered room [ROOM NUMBER] and obtained a blood pressure. Interview with LPN #63 on 03/04/19 at 3:37 P.M., revealed Resident #28 was no longer in contact isolation. She stated the resident was in isolation, however, was taken out the beginning of the week. She confirmed she did not wear gloves nor any other PPE while obtaining Resident #28's blood pressure. LPN #63 confirmed she did not wash or sanitize her hands after obtaining Resident #28's blood pressure. Additionally, LPN #63 confirmed she did not sanitize the dinamap after obtaining Resident #28's blood pressure and prior to moving onto the next resident. Interview with the DON on 03/04/19 at 3:42 P.M., confirmed Resident #28 had an order to be in contact precautions [MEDICAL CONDITION] in the wound. He stated staff should be wearing gloves when they were providing care to him. An additional interview with the DON on 03/04/19 at 4:02 P.M., confirmed there was no isolation sign on the door to see the nurse before entering and confirmed there should have been. Interview with Corporate Nurse #500 on 03/04/19 at 4:07 P.M., confirmed the dinamap should have been sanitized after obtaining Resident #28's blood pressure. Review of the facility policy titled, Glucometer Cleaning and Control Test Guidelines, dated 08/02/17, revealed the Center for Disease Control (CDC) indicated the [MEDICAL CONDITION] Virus (HBV) can survive for at least one week in dried blood on environmental surfaces or on contaminated instruments. The following procedures provide the guidance for cleaning and decontamination of glucometers that may be contaminated with blood and body fluids . The procedure indicated if glucometers were used from one resident to another, they should be cleaned and disinfected after each use. Review of the manufacturers's recommendations for Cleaning and Disinfecting the Meter, revealed the meter should be cleaned and disinfected after use on each resident. The recommendation indicated the disinfection procedure was needed to prevent the transmission of blood-borne pathogens. It revealed a variety of the most commonly used registered wipes that have been tested and approved for cleaning and disinfecting of the Assure Prism multi blood glucose monitoring system. The disinfectant wipes listed below have been shown to be safe for use with this meter. The wipes identified were: Clorox Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels and Bleach, PDI Super Sani-Cloth Germicidal Disposable Wipe and CaviWipes. Review of the facility policy titled, Medication Administration-General Guidelines, dated 11/18, revealed the person administering medications adheres to good hand hygiene before beginning medication administration, prior to handling any medications, after coming into direct contact with a resident, before and after administration of ophthalmic, topical, vaginal, rectal, and [MEDICATION NAME] preparations and before and after administration of medications via enteral tubes. The policy also revealed hand hygiene was to be performed before putting on examination gloves and upon removal for administration of ophthalmic medications. Review of the facility policy titled, Guidelines for Contact Precautions, dated 05/22/18, revealed the purpose was to prevent the spread of infectious disease organisms. The policy addressed standard precautions such as wearing gloves, good hand washing before, after and between residents should always be followed. The policy indicated to wear gloves before contact with the resident or environmental objects and change gloves and wash hands after having direct contact with the resident, possible infective material, or potentially contaminated environmental objects and between each resident care intervention. Further review of the policy indicated a stethoscope, thermometer, and scissors for care should be dedicated to the individual resident and left in the room. If use of common equipment was unavoidable, then adequate cleaning and disinfecting was necessary before use with other residents. The policy revealed to post a sign at the resident's door to advise the visitors to report to the nurse's station before entering the room.

Based on medical record review and staff interview, the facility failed to assess the cognitive status on the comprehensive Minimum Data Set (MDS) assessment (Section C) for five (#28, #31, #32, #36, and #198) out of 17 residents reviewed for MDS assessments. The census was 43. Findings include: 1. Medical record review for Resident #31 revealed an admitted d on 03/05/18. Medical [DIAGNOSES REDACTED]. Review of the annual MDS assessment, dated 02/08/19, revealed she was not assessed for cognitively status. 2. Review of medical record for Resident #32 revealed he was admitted on [DATE]. Medical [DIAGNOSES REDACTED]. Review of the significant change MDS assessment, dated 02/08/19, revealed the resident wasn't assessed for cognitive status. 3. Review of Resident #28's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the admission MDS assessment, dated 01/30/19, revealed a Brief Interview for Mental Status (BIMS) interview should be conducted, however, Resident #28's BIMS was not assessed. 4. Review of the medical record for Resident #36 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the comprehensive MDS assessment, dated 02/19/19, revealed Section C was not completed. 5. Review of the medical record for Resident #198 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #198's comprehensive MDS assessment, dated 02/24/19, revealed Section C was not completed. Interview with Social Worker #51 on 03/05/19 at 3:50 P.M. revealed she wasn't able to complete the interview for Section C for Resident #28, #31, #32, #36, and #198. She stated if she wasn't able to complete the assessment in the assessment reference date timeframe the assessment should have a dash in the interview, which means there were dashes in all the areas of the Section C except for the first question which was should a BIMS be conducted.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident on anti-psychotic medications was assessed for side effects and the failed to ensure non-pharmacological interventions were initiated before an as needed pain medication was given. This affected one (#32) of five residents reviewed for unnecessary medications. The census was 43. Findings include: Review of medical record for Resident #32 revealed he was admitted on [DATE]. Medical [DIAGNOSES REDACTED]. Review of the 14 day Minimum Data Set (MD) assessment, dated 11/08/18, revealed he was cognitively impaired. Review of physician orders [REDACTED]. Review of the Abnormal Involuntary Movement Scale (AIMS) assessment, for side effects of anti-psychotic medication, revealed the last assessment was completed on 06/01/18. Review of care plan dated 06/01/18 for anti-psychotic drug use for Resident #32 revealed an intervention to perform AIMS testing per guidelines of the facility. Interview with Director of Health Services (DHS) on 03/06/19 at 4:41 P.M. verified Resident #32 should have an AIMS assessment had not been completed since 06/01/18 and should be conducted every six months. Review of policy titled Abnormal Involuntary Movement Scale, dated 05/22/18, revealed the AIMS assessment will be repeated for residents taking an anti-psychotic medication every six months or as needed for displaying symptoms of tardive dyskinesia. Additionally, review of physician orders [REDACTED].#32 revealed the pain medication [MEDICATION NAME] tablet 5-325 mg was ordered every six hours as needed for pain. Review of care plan for pain dated 06/01/18 revealed to attempt non-pharmacological interventions for as needed pain medication. Review of Medication Administration Record [REDACTED]. Interview with DHS on 03/06/19 at 5:20 P.M. verified there were no attempts for non-pharmacological interventions before as needed pain medication was administered to Resident #32.

Based on observation, staff interview, and policy review, the facility failed to routinely ensure controlled medication were present and accounted for in one (400 Hall) out of two medication room refrigerators. The census was 43. Findings include: Observation of the locked narcotic box in the medication room on the 400 Hall on 03/07/19 at 2:10 P.M. revealed there was a package with two vials of the anti-anxiety medication lorazapam 2 milligram/milliliters in the refrigerator. Review of Contingency Controlled Substance Inventory Log dated from 02/25/19 through 03/06/19 revealed the logs did not have the name of the drug or dosage and was not signed off as being present and accurate by anyone on 2/27 for the night shift, 2/28 for the day, evening and the night shift, 03/03 for the day, evening, and night shifts, 03/04 for the day, evening and night shifts, 03/05 for evening and night shifts, and 03/06 for the day, evening and night shift. Interview with Licensed Practical Nurse (LPN) #47 on 03/07/19 at 2:12 P.M. verified the nurses who worked those above mentioned shifts did not sign off the lorazapam vials were present and counted. Review of facility policy titled Guidelines for Narcotic Counts, dated 09/23/18, revealed each controlled drug shall have a corresponding count sheet to track distribution and the narcotic book shall contain a sheet providing space for the off going and oncoming nursing staff to record their signature indicating the narcotics had been reviewed.

Based on medical record review, staff and resident interviews, and policy review, the facility failed to ensure care conferences were conducted on a routine basis for one (#31) of one residents reviewed for care conferences during the annual survey. The census was 43. Findings include: Medical record review for Resident #31 revealed an admitted d on 03/05/18. Medical [DIAGNOSES REDACTED]. Review of care conferences for Resident #31 revealed there was no evidence of a care conference after 06/25/18. Interview with Resident #31 on 03/04/19 at 3:51 P.M. revealed she the facility only held two care conferences for her since admission. Interview with Director of Social Services #1 on 03/05/19 at 2:00 P.M. verified there was no care conference conducted after 06/25/18 for Resident #31. Review of policy titled Resident's First Meeting Guidelines, dated 05/22/18, revealed the purpose was to facilitate communication and participation regarding the resident's plan of care, medical condition, and care needs between the resident, family, responsible party, and care giver. The policy further revealed a care conference should be conducted at a minimum quarterly and with every significant change.

Based on medical record review and staff interview, the facility failed to complete the cognitive section of the quarterly Minimum Data Set (MDS) assessments (Section C) for two (#8 and #13) out of 17 residents reviewed for MDS assessments. The census was 43. Findings include: 1. Review of medical record revealed Resident #8 was admitted on [DATE]. Medical [DIAGNOSES REDACTED]. Review of quarterly MDS assessment, dated 12/13/18, revealed Resident #8 was not assessed for cognitive patterns. 2. Review of Resident #13's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #13's quarterly MDS assessment, dated 12/17/18, revealed a BIMS interview should be conducted, however, Resident #13's Brief Interview for Mental Status (BIMS) was not assessed at any point during the seven day assessment reference date time period. Interview with Social Worker #51 on 03/05/19 at 3:50 P.M. revealed she wasn't able to complete the interview for Section C for Resident #8 and #13. She stated if she wasn't able to complete the assessment in the assessment reference date timeframe the assessment should have a dash in the interview, which means there were dashes in all the areas of the Section C except for the first question which was should a BIMS be conducted.

Based on medical record review, staff interview, and policy review, the facility failed to issue written notice of the bed hold policy to a resident/resident's representative. This affected two (#13 and #32) of three residents reviewed for hospitalization s. The facility census was 43. Findings include: 1. Review of Resident #13's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #13's medical record revealed the resident was sent out to the hospital on [DATE] and returned on 12/10/18. There was no evidence in Resident #13's medical record that the resident and/or resident representative was notified in writing of the bed hold policy or bed hold days. Interview with Corporate Registered Nurse #500 on 03/07/19 at 12:59 P.M. confirmed there was no evidence written notification was provided to the resident and/or resident representative regarding their bed hold policy. Review of the facility policy titled Bed Hold Policy, dated 11/23/16, revealed the campus will inform the residents in advance of their option to make bed-hold payments as well as the amount of the facility's charge to hold a bed. 2. Review of medical record for Resident #32 revealed he was admitted on [DATE]. Medical [DIAGNOSES REDACTED]. Review of progress notes dated 10/17/18 for Resident #32 revealed he was taken to the hospital and returned on 10/25/18. The note revealed a bed hold notification was given to the paramedics at the time of leaving the facility. Review of progress notes dated 11/25/18 at 8:00 P.M. revealed Resident #32 was sent to the hospital when he became difficult to arouse. He returned on 11/30/18. The note was absent for a bed hold notice. Review of progress notes dated 12/13/18 at 7:53 A.M. Resident #32 was send out to the hospital and returned on 12/18/18. The note revealed the bed hold notice was sent with the resident to the hospital. Interview with Business Office Manage #501 on 03/07/19 at 11:42 A.M. revealed she wasn't able to find a bed hold notification for Resident #32. Interview with Corporate Registered Nurse (CRN) #500 on 03/07/19 at 11:46 A.M. stated the bed hold policy paperwork was located at the nursing station should be charted in the nursing progress notes that it was given.

Based on medical record review and staff interview, the facility failed to issue written notice of the reasoning for transfer to the hospital to the resident and/or resident representative. This affected two (#13 and #32) of three residents reviewed for hospitalization s. The facility census was 43. Findings include: 1. Review of Resident #13's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #13's medical record revealed the resident was sent out to the hospital on [DATE] and returned on 12/10/18. There was no evidence in Resident #13's medical record that the resident and/or resident representative was notified in writing the reasoning for the transfer to the hospital. Interview with Corporate Registered Nurse #500 on 03/07/19 at 12:59 P.M. confirmed there was no evidence written notification was provided to the resident and/or resident representative for the reasoning for the transfer to the hospital. 2. Review of medical record for Resident #32 revealed he was admitted on [DATE]. Medical [DIAGNOSES REDACTED]. Review of progress notes dated 10/17/18 for Resident #32 revealed he was taken to the hospital for a suspected fracture. The resident returned on 10/25/18. The note was silent to information regarding transfer discharge paperwork for the resident. Review of progress notes dated 11/25/18 at 8:00 P.M. revealed Resident #32 was sent to the hospital. He returned on 11/30/18. The note was absent for transfer discharge paperwork being sent with the resident to the hospital. Interview with Business Office Manage #501 on 03/07/19 at 11:42 A.M. verified she couldn't find information regarding transfer discharge paperwork for Resident #32. Interview with Corporate Registered Nurse (CRN) #500 on 03/07/19 at 11:46 A.M. stated the transfer discharge paperwork was located at the nursing station and would be sent with the resident to the hospital and should be charted in the nursing progress notes.

Based on medical record review and staff interview, the facility failed to ensure the physician's order for a resident's code status matched the State of Ohio Do Not Resuscitate (DNR) document. This affected one (#23) of one residents reviewed for advance directives. The facility census was 43. Findings include: Review of Resident #23's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment identified the resident as being cognitively intact. Review of Resident #23's physician's orders revealed an order identifying the resident as being a full code. This order was initiated on 05/16/18. Review of the State of Ohio Do Not Resuscitate document identified the resident as requesting a Do Not Resuscitate Comfort Care (DNRCC) status. This was signed by the physician on 03/01/19. Interview with Corporate Nurse #500 on 03/06/19 at 12:17 P.M. confirmed the resident had a signed and advanced directive identifying the resident as being a DNRCC. However, she confirmed Resident #23's physician's order indicates the resident as being a full code.

Based on medical record review, staff interview, and policy review, the facility failed to ensure transportation was arranged for a wound clinic appointment for one (#28) of one resident reviewed for non-pressure related skin conditions. The facility census was 43. Findings include: Review of Resident #28's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 01/30/19, revealed the resident required extensive assistance of two person for bed mobility and extensive two person assist with transfers. Review of the physician orders dated 02/14/19 revealed the resident had appointments on Fridays at the wound clinic. Review of Resident #28's progress notes revealed on 02/21/19 at 6:50 P.M. Resident #28's friend can into visit and notified the nurse he would no longer be able to transport the resident to and from the wound clinic on Fridays. The nurse informed management of the change. Further review of Resident #28's nurses notes failed to identify any evidence the facility attempted to schedule transport for Resident #28's appointment to the wound clinic for 02/22/19. Interview with the Director of Nursing (DON) on 03/06/19 at 1:47 P.M. revealed Resident #28 was scheduled to have a wound clinic appointment on 02/22/19. He voiced Resident #28's friend was the one who had been transporting the resident to his appointment and on 02/21/19 the residents friend informed them he was unable to transport the resident anymore. Additional interview with the DON on 03/06/19 at 2:17 P.M. revealed their transport bus was unavailable on 02/22/19 to transport the resident. The DON verified they did not try to get transport arranged for Resident #28's appointment on 02/22/19 after they found out the resident's friend was unable to transport. Review of the facility policy titled Transportation Guidelines, dated (MONTH) 31, (YEAR), revealed transportation was provided from the hospital to a campus, to medical appointments by bus or car, for campus outings and various trips. It indicated nursing should fill out all necessary sections of the Transportation Request Form and submit to the Transportation Associate (TA) at least 48-72 hours in advance of an appointment. If the transportation request is declined, the TA should notify nursing, so that the nurse can schedule alternate transportation.