Advanced Healthcare Center

Based on observation, and staff interview the facility failed to ensure resident rooms were clean and equipment was adequately maintained. This affected three (#11, #37, and #30) of 24 residents reviewed for environmental services, The facility census was 83. Findings include:1. Observation on 01/26/26 at 6:42 P.M. revealed an area of Resident #37's wall with gouges in the drywall and exposed drywall underlayment behind the head of the bed. The area measured approximately five foot by five foot.
Additional observation on 01/28/26 at 6:15 A.M. noted the wall located to the right of Resident #37's bed with a liquid appearing splatter debris covering the wall and to the right of the bed a maroon mat on the floor with the same debris.
On 01/28/2026 at 8:15 A.M. observation with Maintenance Director #319 of Resident #37's room verified the gouges in the wall behind Resident #37's head of the bed.
On 01/28/2026 at 8:21 A.M. observation with the Director of Environmental Services (ES) #499 verified the debris on the wall and next to Resident #37's bed. ES #499 stated resident has a behavior of spitting. ES #499 was unable to indicate the most recent time the wall or floor matt were cleaned.
2. Observation on 01/28/2026 at 8:41 A.M. noted Resident #11's room wall to the left of the bed with gouges in the drywall and white unpainted drywall patches. The area measured approximately five foot by three foot.
On 01/28/26 at 8:43 A.M. interview with the Maintenance Director #319 verified the gouges and unpainted patches to the wall inside Resident #11's room.
3. Observation on 01/27/26 at 10:55 A.M. revealed a tube feeding pump mounted on a pole next to Resident #30's bed, the legs of the pole had a puddle of fresh tube feeding on the legs along with older dried tube feeding covering the legs of the pole. Under the pole on the floor there was a small puddle, approximately two inches in diameter of tube feeding.
Interview on 01/27/26 at 11:02 A.M. with the Director of Risk Management #500 verified the tube feeding on the legs of the pole and floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure fall prevention interventions were implemented and fall occurrences were thoroughly investigated. This affected one (#4) of one resident reviewed for fall incidents and related interventions. The facility census was 83.Findings include:Review of the medical record revealed Resident #4 admitted to the facility on [DATE], diagnoses included atrial fibrillation, bipolar disorder, schizoaffective disorder, major depressive disorder, anxiety disorder, left and right knee contractures. According to the most current Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 with moderately impaired cognition, lower extremity range of motion impairment on one side, a dependency on staff for the completion of activities of daily living, and transfers. Resident #4 was incontinent of bowel and bladder, had no skin breakdown, was at risk for pressure ulcer development, and was receiving an anticoagulant, opioids, and anticonvulsant medications. On 08/09/25 a nursing plan of care was developed to address Resident #4's history of falling, the plan of care was revised on 12/04/25. Interventions included to ensure anti-tippers are in correct position on the wheelchair, to ensure the resident was wearing appropriate non-skid footwear, encourage the resident to call for help with transfers, to encourage the resident and staff to keep the wheelchair close to the side of the bed, and for non-skid strips on the floor next to bed. Review of the medical record revealed on 12/09/25 a fall follow-up assessment was completed from a fall sustained on 12/03/25. Intervention included for the the care plan updated. On 12/25/25 a fall risk assessment was completed and scored the resident at risk of falling. The assessment noted Resident #4 had previously sustained falls within the past two to six months. Review of nursing progress note dated 12/25/25 at 1:00 A.M. revealed Resident #4 was observed sitting on the floor, on his buttocks next to his bed. Resident #4 stated he was crawling on the floor to get in his wheelchair. Resident #4 denied hitting his head, had no complaints of pain or discomfort, and exhibited no signs or symptoms of distress. Resident #4 had a blood pressure of 112/72 , and a heart rate of 72. The resident was educated on the importance of using the call light and waiting for assistance. Resident #4 was assisted off the floor by two staff members and placed in the wheelchair. Review of the facility occurrence report dated 12/25/25 and timed 1:00 A.M. noted Resident #4 sustained a fall during a transfer in the resident's room. The occurrence report contained no documentation of what fall interventions were in place at the time of the fall, how long the resident had been on the floor, or any potential witnesses or resident specific interventions implemented to address fall incident.Interview on 01/29/26 at 12:45 P.M. with the Director of Nursing (DON) verified the nursing progress note, and the facility occurrence report for Resident #4's fall on 12/25/25 contained no documentation of what fall interventions were in place at the time of the fall, or the reason why the resident attempted to self transfer. Additionally, the DON verified the fall investigation was not thorough as the the missing information was not requested, no witness statements regarding the fall were obtained and there was not a review of current interventions care planned for to ensure the interventions had been effectively implemented. Observation on 01/28/26 at 6:12 A.M. Resident #4 was noted in bed with his eyes closed. The resident's head of the bed elevated, bilateral grab bars were in place, and the resident's specialized wheelchair was located at foot of bed. Both sides of the bed were open to the room, no non-skid strips were in place on the floor to the right side of the bed. At 8:58 A.M. Resident #4 was seated on the right side of the bed, with feet to floor.According to updated facility fall prevention policy, fall investigations are to include asking the resident what they were doing when they fell, identify if there were any witnesses to the fall and if so, obtain a written witness statement of what they saw. The interdisciplinary team (IDT) is to review all information from a fall at the next daily clinical meeting and discuss the fall to include potential causes, interventions in place at time of the fall to determine if they were effective, and review of the resident's care to identify if interventions were appropriate or if new interventions should be added.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure one resident's indwelling urinary catheter was maintained in a sanitary manner. This affected one (#37) of three residents reviewed for indwelling urinary catheters. The facility census was 83. Findings include: Review of the medical record for Resident #37 revealed an admission date of 09/23/25, diagnoses included metabolic encephalopathy, severe protein calorie malnutrition, benign prostatic hyperplasia, obstructive and reflux uropathy, hydronephrosis, hypertension, dementia, myocardial infarction, and resistance to Vancomycin. According to the most current Minimum Data Set (MDS) assessment dated [DATE], Resident #37 had severely impaired cognition, had physical and verbal behavioral symptoms one to three days, rejected care one to three days, was dependent on staff for the completion of activities of daily living including transfers and bed mobility, utilized an indwelling urinary catheter, was incontinent of bowel, and was at risk for pressure ulcer development with no current skin breakdown. On 09/25/25 a plan of care was implemented and on 11/28/25 the plan of care was revised to address Resident #37's indwelling urinary catheter due to obstructive uropathy and benign prostatic hypertrophy. Interventions included to position the catheter bag and tubing below the level of the bladder, to provide privacy bag, and to secure the drainage catheter to the resident's leg with securement device. Review of a physician order dated 10/31/25 revealed a urinary indwelling catheter was to placed to continuous drainage. On 01/14/26 a physician order was written for the administration of Levofloxacin (antibiotic) 750 milligrams (mg) each morning due to a urinary tract infection of bacteremia. Observation on 01/26/26 at 6:42 P.M. Resident #37 was in bed with the indwelling urinary catheter drainage bag laying on the floor under the bed.Observation on 01/26/26 at 9:15 P.M. the indwelling urinary catheter drainage bag was observed to remain on the floor under Resident #37's bed. Interview on 01/26/26 at 9:16 P.M. with Certified Nurse Aide (CNA) #398 stated Resident #37 was in contact isolation due to an infection in his urine (methicillin resistant staphylococcus aureus). CNA #398 also verified the indwelling urinary catheter drainage bag was laying on the floor under the bed and stated the drainage bag should be secured to the bed frame. Observation on 01/27/26 at 3:09 P.M. Resident #37 was in bed with the indwelling urinary catheter drainage bag laying on the floor next to the bed.Observation on 01/29/26 at 6:05 A.M. Resident #37 observed in bed with the indwelling urinary catheter drainage bag on end of bed at the level of his bladder.On 01/29/26 at 6:08 A.M. interview with CNA #398 verified the urinary catheter bag was not below the level of Resident #37's bladder and it should be to prevent the backflow of urine into the resident's bladder.On 01/29/26 at 10:34 A.M. interview with Registered Nurse #342 verified the facility indwelling urinary catheter policy included for staff to ensure the collection bag is not on the floor, was draining properly and secured to the bed, below the level of the bladder so there is no reflux of urine back into the bladder. Review of the undated facility policy titled Catheter Care stated staff are to ensure the drainage collection bag is not on the floor, urine is draining properly, and the urinary drainage bag secured below the level of the resident's bladder to prevent reflux of urine back to the bladder. This deficiency represents non-compliance investigated under Complaint Number 2715485.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure narcotic medications were administered and maintained in a secured manner. This affected four (#64, #72, #93, and #94) of 18 residents receiving narcotic medications residing on the 400 unit. The facility census was 83. Findings include: Observation on 01/26/26 at 6:52 P.M. noted Licensed Practical Nurse (LPN) #370 and LPN #316 conducting a shift change narcotic medication and controlled substance inventory for the 400 unit medication cart. LPN #316 was observed to be removing narcotic medication cards from the 400 unit medication cart and counting the number of medications (tablets, contents) on each card and reporting the count to LPN #370. LPN #370 was observed reviewing the controlled substance inventory log for each narcotic and controlled substance contained in the 400 unit medication cart to verify with the count reported. Thirty-nine narcotic medication cards were contained in the locked narcotics drawer in the 400 unit medication cartInterview with LPN #316 at the time of the observation verified he was assuming care of the residents on the 400 unit for the 6:30 P.M. until 7:00 A.M. shift on 01/26/26. Interview with LPN #370 revealed she was finishing her shift and had been assigned to provide care to the residents on the 400 unit from 6:30 A.M. until 7:00 P.M. Continued observation noted LPN #319 removed Resident #64's medication card containing 17 Hydrocodone-acetaminophen 10-325 milligrams (mg). LPN #370 stated the controlled substance inventory log for the Hydrocodone-acetaminophen 10-325 mg noted 18 tablets. LPN #319 removed a second medication card for Resident #63 with 47 tablets of Clonazepam 0.5 mg. LPN #370 stated the controlled substance inventory log displayed a current inventory of 48 tablets. Interview with LPN #370 at the time revealed she had given the medications to Resident #64 during the shift, but did not sign the medications out as administered on the controlled substance log.Continued observation revealed LPN #319 removed Resident #72's medication card containing a physical count of 19 oxycodone 5 mg tablets. LPN #370 stated the count on the controlled substance log log stated there should be 20 tablets remaining. LPN #319 then removed a medication card containing Resident #93's oxycodone 15 mg tablets, the physical count was 18 tablets. LPN #370 reported the count on the controlled substance log was 19. Further observation revealed LPN #319 remove Resident #94's Pregabalin 150 mg medication card from the cart, there was a physical count of 54 tablets. LPN #370 reported 55 tablets were currently listed in the inventory on the controlled substance log.On 01/26/26 at 7:05 P.M. interview with LPN #370 revealed she had administered the narcotic medications to the specified residents (#72, #93 and #94) during the shift however, she was extremely busy and did not record the medications as administered on the controlled substance log at the time of the administration. LPN #370 and LPN #319 verified narcotics and controlled substances are to be signed out on the controlled substance log at the time of administration. Interview on 01/26/26 at 9:20 P.M. with the Director of Nursing verified narcotic medications are to be signed out on the Medication Administration Record and on the Controlled Substance Log at the time of administration immediately after they are removed from the medication cart. According to undated Medication Administration policy, narcotics will be signed out when administered.

Based on observation, staff interview, and policy review, the facility failed to maintain a reach in refrigerator at a safe temperature, failed to date and label food items, and failed to maintain a sanitary environment. This had the potential to affect all residents in the facility receiving food from the kitchen, except for Resident's #11, #30, #76, #88, and #89 who were identified by the facility as not receiving food by mouth. The facility census was 83.Findings include:On initial tour of kitchen on 01/26/26 from 6:10 P.M. until 6:26 P.M. revealed at 6:10 P.M. the reach in refrigerator located approximately three feet across from steam table had both doors propped open by serving carts, inside the refrigerator were 15 cups of grape juice, five cups of cranberry juice, 11 cups of orange juice, 26 cups of lemonade, six cups of milk, and 18 cups of an unidentified liquid, all cups were labeled but contained no dates. The inside thermometer for the refrigerator was reading 58 degrees Fahrenheit (F). Interview with Dietary Aide #337 at the time of the observation revealed that the doors were propped open to make it easier to access the prepared cups of juice being placed on the resident's meal trays. Dietary Aide #337 confirmed the various cups of liquids should have been dated to indicated when they were prepared.Continued observation on 6:21 P.M. revealed a resident's meal tray which had been eaten from was sitting on top of a smaller reach in cooler located next to the service door. Interview on 01/26/26 at 6:21 P.M. with Dietary Aide #337 confirmed the tray containing partially eaten food was placed on the reach in cooler after being brought into the kitchen from the dining room.Continued observation of the walk in cooler at 6:26 P.M. revealed two open containers of pudding, one open container of sour cream, and one open container of chicken salad all without labels indicating the dates opened. Also observed in the walk in cooler was a package of opened and undated tortillas on the right side second shelf. Interview on 01/26/26 at 6:26 P.M. with [NAME] #339 confirmed the items listed did not have labels indicating when they were opened.Review of policy titled Food Storage: Cold Foods, with a revised date of 02/2023, revealed that all perishable foods will be maintained at a temperature of 41 degrees F, or below and that all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.Review of policy titled Environment with a revision date of 06/2025, revealed that all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, resident interview, staff interview, and policy review, the facility failed to ensure vision services were provided timely. This affected one (#3) of two residents reviewed for vision services. The facility census was 83. Findings include: Review of the medical record for Resident #3 revealed an admission date of 09/22/25. Diagnoses included hemiplegia and hemiparesis, chronic obstructive pulmonary disease, hypertension, anxiety, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Further review of the MDS assessment revealed the resident had no corrective lenses. Review of a request for services form dated 09/24/25 revealed the resident had requested to be seen for eye care. Review of the vision provider schedule dated 10/27/25 revealed the provider was in the facility and Resident #3 was not seen by the provider. Review of the progress notes dated 09/25/25 through 01/28/26 revealed no documentation the resident had been provided eye care services as requested. Interview on 01/26/26 at 8:52 P.M., Resident #3 revealed she had requested to see the eye doctor a while ago and had not seen the provider.Interview on 01/28/25 at 9:02 A.M., Social Service Designee (SSD) #404 revealed the eye care provider was last in the facility on 10/27/25 and had not seen Resident #3. SSD #404 verified Resident #3 had not been provided with vision services since her admission to the facility. SSD #404 revealed the facility changed providers at the end of 12/2025 and the new provider also had not been in the building yet to provide vision services for the residents. Review of the undated facility policy Social Services, revealed social services would help and support residents in addressing concrete service needs including referrals for eye care, dental care, podiatry, and durable medical equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to administer a diuretic and insulin as ordered within a specified time frame for one (#3) out of seven patients reviewed in a census of 87. Findings include: Review of the medical record revealed Resident #3 admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with chronic obstructive pulmonary disease, type 2 diabetes mellitus, cerebral infarction, hypertension, congestive heart failure, major depressive disorder, chronic viral hepatitis C, anxiety disorder, systemic lupus erythematosus, alcohol abuse, opioid abuse, and cognitive communication deficit. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #3 had severe cognitive impairment, no recorded behaviors, and required substantial to maximal assistance with activities of daily living.Review of the medication administration record and physician orders revealed orders for diuretic hydralazine 100 milligram (mg) tablet three times daily at 8:00 A.M., 2:00 P.M. and 10:00 P.M. and Insulin Aspart Flexpen sliding scale- blood sugar (bs) 151-200 give (=) 3 units, bs 201-250= 6 units, 251-300= 9 units, 301-350= 12 units, 351-400= 15 units, 401-450= 20 units, call physician (MD) if bs above 400 or below 70, administer subcutaneous before meals and at bedtime scheduled 7:00 A.M., 11:00 A.M., 4:00 P.M., and 9:00 P.M.Review of medication administration audit report revealed the hydralazine 100 mg and Insulin Aspart Flexpen three (3) units were scheduled for 07/04/25 at 9:00 P.M. The medications were not administered until 07/05/25 at 12:28 A.M.Telephone interview on 07/09/25 at 12:22 P.M. with Licensed Practical Nurse (LPN) #200 verified she was assigned to administer medications to Resident #3 on 07/04/25 evening (P.M.). Resident #3 was sleeping and the medications were not administered within prescribed timeframes. LPN #200 verified the physician was not notified of the medications being given outside of prescribed timeframes and no entry was made in the medical record indicating the reason the medications were provided late. Review of facility policy titled Medication Administration revealed medications will be administered within the time frame of one hour before up to one hour after ordered time. Medications that are refused or withheld or not given will be documented. Critical medications that are refused including insulin or anticoagulants will be followed up with physician contact. Documentation of medications will follow accepted standards of nursing practice. On 07/10/25 at 8:34 A.M. interview with the Director of Nursing confirmed Resident #3's medications were documented to be administered outside of prescribed time frames. No documentation was contained in the medical record indicating a reason for late medication administration. This deficiency represents non-compliance investigated under Complaint Number OH00167398/ iQIES Complaint Number 1326898.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident and staff interview and facility policy, the facility failed to thoroughly investigate an allegation of staff to resident physical abuse. This affected one (#3) of seven residents reviewed for staff to resident care and treatment in a facility census of 87. Findings include:Review of the medical record revealed Resident #3 admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with chronic obstructive pulmonary disease, type 2 diabetes mellitus, cerebral infarction, hypertension, congestive heart failure, major depressive disorder, chronic viral hepatitis C, anxiety disorder, systemic lupus erythematosus, alcohol abuse, opioid abuse, and cognitive communication deficit. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #3 had severe cognitive impairment, no recorded behaviors, and required substantial to maximal assistance with activities of daily living. The medical record contained no documentation of Resident #3 making any allegation of abuse from a staff member. On 07/09/25 at 8:15 A.M. interview with Administrator and Director of Nursing (DON) revealed Resident #3's responsible party had made an allegation of staff to resident abuse. Resident #3's responsible party was unable to articulate when or what alleged incident took place until 07/08/25. The DON stated an alleged nurse resigned on date of alleged event of 07/05/25 in the early morning during the 6:00 P.M. to 6:00 A.M. shift. On 07/09/25 at 8:58 A.M. interview with Resident #3 revealed she was hit with bed controller in the chest by a nurse aide. Resident #3 was unable to stated the date or provide any additional information. Telephone interview on 07/09/25 at 12:23 P.M. with the alleged nurse, Licensed Practical Nurse (LPN) #200, revealed she assumed care of Resident #3 on 07/04/25 at 6:30 P.M. and was scheduled to work until the morning of 07/05/25 at 7:00 A.M. Between 11:30 P.M. and 12:00 A.M. LPN #200 went to administer medications to Resident #3. Resident #3 requested the medications crushed. LPN #200 proceeded to crush the medications, placed them in applesauce, and returned to Resident #3's bedside. LPN #200 obtained the electric bed controller from Resident #3's chest, raised the head of the bed, and placed the controlled next to the resident on the mattress. Resident #3 then became agitated and started yelling LPN #200 had hit her in the chest with the bed remote. LPN #200 attempted to calm Resident #3 and denied hitting her. Resident #3 continued yelling and Certified Nurse Aide (CNA) #400 entered the room. Once CNA #400 entered the room LPN #200 left the room and contacted her supervisor ( Registered Nurse (RN) #201) via telephone and reported Resident #3 was accusing her of hitting her and this was an allegation of physical abuse. LPN #200 informed RN #201 she was leaving the facility and turned her medication cart keys over to LPN #202. At approximately 12:30 A.M. Resident #3's son came to the facility and proceeded to Resident #3's room. Resident #3's son then approached LPN #200 at the nurses station and began cursing and threatening LPN #200. LPN #200 turned over care of her residents to LPN #202 until RN #201 reported to the facility. LPN #200 proceeded to leave the facility at 1:00 A.M. LPN #200 stated she did not provide a statement regarding the incident or document the incident in Resident #3's medical record. Interview on 07/10/25 at 5:15 A.M. with CNA #400 revealed she was assigned to Resident #3's care on 07/04/25. She was walking down the hall when she heard yelling coming from Resident #3's room. CNA #400 went to check on the resident. Upon entering the room LPN #200 was standing outside the room and told CNA #400 Resident #3 was alleging she hit her with the bed remote. Resident #3 was yelling out and LPN #200 stated she was leaving the facility due to the allegation or physical abuse. CNA#400 provided Resident #3 with incontinence care and observed no potential injury and exited the room. Following care LPN #200 was observed at her medication cart and told CNA #400 she had notified the supervisor RN and she was leaving due to the allegation of physical abuse. Approximately 10 minutes later RN #201 was observed counting the medication cart and assuming care to the residents on the hall. LPN #200 proceeded to leave the facility. CNA #400 stated she did not provide a statement following the incident. On 07/10/25 at 5:19 A.M. interview with CNA #401 revealed on 07/04/25 she was working in a resident room on the 400 Hall and came out seeing LPN #200 packing her bag at the nursing station. LPN #200 was stating she would not be coming back to the facility. LPN #200 stated Resident #3 alleged LPN #200 had hit the resident with the bed remote. RN #201 had assumed care of her residents. On 07/10/25 at 5:46 A.M. interview with RN #201 revealed on 07/05/25 at 12:37 A.M. she received a phone call from LPN #200 stating Resident #3 accused her of throwing a bed remote at her and LPN #200 was reporting the alleged incident to her supervisor. RN #201 stated she phoned the DON immediately after speaking with LPN #200. RN #201 told the DON Resident #3 alleged LPN #200 threw the bed remote and hit her in the face. RN #201 took another phone call and returned a phone call to the DON at 12:45 A.M. on 07/05/25. RN #201 informed the DON LPN #200 was going to leave and RN #201 was going in to assume care. Approximately 20-25 minutes later RN #201 reported to the facility and LPN #200 had left. RN #201 spoke with Resident #3 who stated the remote hit her in the leg. No marks were identified on Resident #3's face and no pain was stated from the resident. RN #201 stated she did not assess Resident #3 for potential injury and did not attempt to take statements from potential witnesses. Interview on 07/10/25 at 6:28 A.M. with the DON revealed she was not informed until 07/08/25 Resident #3 had reported alleged physical abuse. On 07/05/25 she was informed by RN #201 that Resident #3 reported her remote was thrown on the bed and not the resident had been struck with the bed remote in the chest. The DON confirmed no documentation was contained in Resident #3's medical record regarding the incident and no physical assessment to identify possible injury was completed. Furthermore, no witness statements had been obtained regarding the incident until 07/08/25 when Resident #3's representative alleged Resident #3 was struck by the bed remote in the chest.Review of facility policy titled Abuse, Neglect, and Misappropriation revealed an employee who is alleged or accused of being party to abuse, neglect, misappropriation of property will be immediately removed from the area (s) of resident care, interviewed by facility leadership for a written statement and not left alone. After completing the statement(s) the employee will be asked to vacate the facility until further investigation of the incident is completed. Each occurrence of resident incident, bruise, abrasion, or injury of unknown source; or report of alleged abuse, neglect to misappropriation of funds will be identified and reported to the supervisor and investigated timely. The supervisor or designee will notify the Director of Nursing and Executive Director (Administrator) of the incident or allegation immediately. The Executive Director will direct the investigation. Documentation of the facts and findings will be completed in each resident medical record. Statements will be obtained from staff related to the incident, including victim, person reporting incident, accused perpetrator and witnesses. By the fifth day, the alleged abuse investigation form is completed and reviewed for completeness and accuracy by the Executive Director or designee and submitted to the state. This citation represents non-compliance discovered during the investigation of Complaint Number OH00167551/ iQIES Complaint Number 1326898.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff and resident interview, review of Self Reported Incidents, and review of facility policy, the facility failed to immediately report an allegation of staff to resident physical abuse immediately to the administrator. This affected one (#3) of seven residents reviewed for staff to resident care and treatment in a facility census of 87. Findings include:Review of the medical record revealed Resident #3 admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with chronic obstructive pulmonary disease, type 2 diabetes mellitus, cerebral infarction, hypertension, congestive heart failure, major depressive disorder, chronic viral hepatitis C, anxiety disorder, systemic lupus erythematosus, alcohol abuse, opioid abuse, and cognitive communication deficit. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #3 had severe cognitive impairment, no recorded behaviors, and required substantial to maximal assistance with activities of daily living.On 07/09/25 at 8:15 A.M. interview with Administrator and Director of Nursing (DON) revealed Resident #3's responsible party had made an allegation of staff to resident abuse. Resident #3's responsible party was unable to articulate when or what alleged incident took place until 07/08/25. The DON stated an alleged nurse resigned on date of alleged event of 07/05/25 in the early morning during the 6:00 P.M. to 6:00 A.M. shift. On 07/09/25 at 8:58 A.M. interview with Resident #3 revealed she was hit with bed controller in the chest by a nurse aide. Resident #3 was unable to stated the date or provide any additional information. Telephone interview on 07/09/25 at 12:23 P.M. with the alleged nurse, Licensed Practical Nurse (LPN) #200, revealed she assumed care of Resident #3 on 07/04/25 at 6:30 P.M. and was scheduled to work until the morning of 07/05/25 at 7:00 A.M. Between 11:30 P.M. and 12:00 A.M. LPN #200 went to administer medications to Resident #3. Resident #3 requested the medications crushed. LPN #200 proceeded to crush the medications, placed them in applesauce, and returned to Resident #3's bedside. LPN #200 obtained the electric bed controller from Resident #3's chest, raised the head of the bed, and placed the controlled next to the resident on the mattress. Resident #3 then became agitated and started yelling LPN #200 had hit her in the chest with the bed remote. LPN #200 attempted to calm Resident #3 and denied hitting her. Resident #3 continued yelling and Certified Nurse Aide (CNA) #400 entered the room. Once CNA #400 entered the room LPN #200 left the room and contacted her supervisor ( Registered Nurse (RN) #201) via telephone and reported Resident #3 was accusing her of hitting her and this was an allegation of physical abuse. LPN #200 informed RN #201 she was leaving the facility and turned her medication cart keys over to LPN #202. At approximately 12:30 A.M. Resident #3's son came to the facility and proceeded to Resident #3's room. Resident #3's son then approached LPN #200 at the nurses station and began cursing and threatening LPN #200. LPN #200 turned over care of her residents to LPN #202 until RN #201 reported to the facility. Interview on 07/10/25 at 5:15 A.M. with CNA #400 revealed she was assigned to Resident #3's care on 07/04/25. She was walking down the hall when she heard yelling coming from Resident #3's room. CNA #400 went to check on the resident. Upon entering the room LPN #200 was standing outside the room and told CNA #400 Resident #3 was alleging she hit her with the bed remote. Resident #3 was yelling out and LPN #200 stated she was leaving the facility due to the allegation or physical abuse. CNA#400 provided Resident #3 with incontinence care and observed no potential injury and exited the room. Following care LPN #200 was observed at her medication cart and told CNA #400 she had notified the supervisor RN and she was leaving due to the allegation of physical abuse. Approximately 10 minutes later RN #201 was observed counting the medication cart and assuming care to the residents on the hall. LPN #200 proceeded to leave the facility. On 07/10/25 at 5:19 A.M. interview with CNA #401 revealed on 07/04/25 she was working in a resident room on the 400 Hall and came out seeing LPN #200 packing her bag at the nursing station. LPN #200 was stating she would not be coming back to the facility. LPN #200 stated Resident #3 alleged LPN #200 had hit the resident with the bed remote. RN #201 had assumed care of her residents. On 07/10/25 at 5:46 A.M. interview with RN #201 revealed on 07/05/25 at 12:37 A.M. she received a phone call from LPN #200 stating Resident #3 accused her of throwing a bed remote at her and LPN #200 was reporting the alleged incident to her supervisor. RN #201 stated she phoned the DON immediately after speaking with LPN #200. RN #201 told the DON Resident #3 alleged LPN #200 threw the bed remote and hit her in the face. RN #201 took another phone call and returned a phone call to the DON at 12:45 A.M. on 07/05/25. RN #201 informed the DON LPN #200 was going to leave and RN #201 was going in to assume care. Approximately 20-25 minutes later RN #201 reported to the facility and LPN #200 had left. RN #201 spoke with Resident #3 who stated the remote hit her in the leg. No marks were identified on Resident #3's face and no pain was stated from the resident. Interview on 07/10/25 at 6:28 A.M. with the DON revealed she was not informed until 07/08/25 Resident #3 had reported alleged physical abuse. On 07/05/25 she was informed by RN #201 that Resident #3 reported her remote was thrown on the bed and not the resident had been struck with the bed remote in the chest. The DON confirmed no documentation was contained in Resident #3's medical record regarding the incident and no physical assessment to identify possible injury was completed. Furthermore, no witness statements had been obtained regarding the incident until 07/08/25 when Resident #3's representative alleged Resident #3 was struck by the bed remote in the chest.Review of the facility Self Reported Incidents revealed on 07/08/25 the facility reported the allegations of staff to resident abuse toward Resident #3 to the State Survey Agency. Review of facility policy titled Abuse, Neglect, and Misappropriation revealed each occurrence of resident incident, bruise, abrasion, or injury of unknown source; or report of alleged abuse, neglect to misappropriation of funds will be identified and reported to the supervisor and investigated timely. The supervisor or designee will notify the Director of Nursing and Executive Director (Administrator) of the incident or allegation immediately. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the Executive Director/designee of the facility. For alleged violations of alleged abuse the facility must report to the state survey agency immediately, but no more than two hours after the allegation is made. This citation represents non-compliance discovered during the investigation of Complaint Number OH00167551/ iQIES Complaint Number 1326898.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, observation, staff interview, and policy review, the facility failed to ensure incontinence care was provided timely. This affected one (#85) of three residents reviewed for incontinence care. The facility census was 83.
Findings include:
Review of the medical record for Resident #85 revealed an admission date of 07/13/20. Diagnoses included osteoporosis, urinary incontinence, hypertension, and dementia.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. The resident was always incontinent of bladder and frequently incontinent of bowel. The resident was dependent on staff for toileting.
Review of the care plan last revised 01/28/25 revealed the resident had urinary and bowel incontinence related to weakness, difficulty ambulating, and cognitive deficits. Interventions included the use of incontinence briefs and incontinence care as needed.
Review of the task documentation for toileting dated 05/27/25 revealed no documentation the resident had been provided incontinence care from 6:30 A.M. through 12:00 P.M.
Observations on 05/27/25 at 9:13 A.M. revealed Resident #85 was sitting in the common area in a wheelchair near the nurses' station watching television.
Interview on 05/27/25 at 9:17 A.M., Resident #85 revealed her incontinence brief had been changed earlier in the morning. Resident #85 revealed the staff were not checking her for incontinence during the day.
Observations on 05/27/25 at 9:17 A.M., 10:01 A.M., 10:40 A.M., and 11:14 A.M., revealed the resident remained in her wheelchair in the common area in front of the television. There were no observations of staff offering to provide the resident incontinence care.
Observation on 05/27/25 at 11:32 A.M., revealed Resident #85 remained in the common area in her wheelchair. There were odors of urine and stool present.
Interview at 11:32 A.M. Resident #85 revealed staff had not offered to change her incontinence brief. Further observations at 11:45 A.M. and 11:59 A.M. revealed the resident remained in the common area with signs of incontinence.
Interview on 05/28/25 at 11:59 A.M., Licensed Practical Nurse (LPN) #202 revealed the resident's nursing assistant was completing incontinence care rounds and had not gotten to Resident #85 yet.
Observation on 05/28/25 at 12:00 P.M. revealed Certified Nursing Assistant (CNA) #404 pushed the resident in her wheelchair down to her room. CNA #404 and CNA #232 transferred the resident to the bed using the standup lift. Further observation revealed a puddle of liquid with a urine odor in the resident's wheelchair on the seat cushion. Continued observations revealed the resident's pants were wet and had a strong urine odor. CNA #404 and CNA #232 provided incontinence care. The resident's incontinence brief was heavily saturated with urine and a small amount of stool. Further observation revealed the resident had no skin breakdown.
Interview on 05/27/25 at 12:01 P.M., CNA #404 revealed her shift began at 10:30 A.M. and was not aware when Resident #85 had last received incontinence care as the prior shift nursing assistance had not let her know. CNA #404 and CNA #232 verified there was a puddle of liquid on the cushion in the resident's wheelchair. CNA #404 and CNA #232 verified the resident's pants were wet with a strong urine odor. CNA #404 and CNA #232 verified the resident had been incontinent of urine and stool and the resident's brief was heavily saturated with urine. CNA #404 and CNA #232 verified incontinence care should be provided every two hours.
Interview on 05/28/25 at 2:34 P.M., the Director of Nursing (DON) revealed as a general rule incontinence care would be provided every two hours or per resident preference.
Review of the undated facility policy Routine Resident Care, revealed routine daily care including incontinence care would be provided.
This deficiency represents non-compliance investigated under Master Complaint Number OH00165598.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigations, staff interview, and review of the facility policy the facility failed to ensure medications were administered to the correct resident. This affected one resident (#89) reviewed for medication errors. The facility census was 92.
Findings include:
Review of the medical record for Resident #89 revealed an admission date of 10/28/24 with diagnoses of follow-up for joint replacement surgery, depression, anxiety, alcohol abuse, and cocaine abuse.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #89 revealed he was cognitively intact and he was not ordered any opioid medication (narcotic pain medication).
Review of the current physician orders for April 2025 for Resident #89 revealed no orders for Gabapentin (medication used for nerve pain), Doxycycline (antibiotic), Metoprolol (used to treat high blood pressure), Norco (narcotic (opioid) pain medication), and Oxycodone (narcotic (opioid) pain medication.
Review of the listed drug allergies for Resident #89 revealed he had an allergy to Aspirin only.
Review of the care plan revised 02/14 for Resident #89 revealed the resident had substance use disorder history of smoking, marijuana, cocaine abuse and alcohol abuse and he now uses his past experiences to help share with others in rehabilitation.
Review of the nursing progress notes for Resident #89 dated 01/31/25 revealed he was administered medication in error the following medications: Gabapentin 100 milligrams (mg), Doxycycline 100 mg, Metropolol 25 mg, and Norco 5/325 mg.
Interview on 03/31/25 at 10:39 A.M. with Resident #89 stated he was involved in two medication errors where he received medication that was not prescribed to him.
Review of the internal investigation for the medication error dated 01/31/25 for Resident #89 revealed Licensed Practical Nurse (LPN) #378 prepared medication for administration and administered the medication to the wrong resident.
Phone interview on 04/02/25 at 4:01 P.M. with LPN #378 stated she was working on 01/31/25 and was passing her medications when there were many different events happening with residents requesting to go out to smoke, Certified Nursing Assistants (CNA) reporting different items to her and two residents with the same name. LPN #378 amidst the distractions she prepared medications for administration and delivered the medication to the wrong resident, Resident #89. LPN #378 further stated Resident #89 requested some Tylenol and she returned to the medication cart and discovered the medication she prepared was for a different resident based on the computer screen that she was working on and then returned to Resident #89 and he had already taken the medication she delivered to him.
Review of the nursing progress notes for Resident #89 dated 03/27/25 revealed he was administered medication in error, Resident #89 was administered Oxycodone five milligrams.
Review of the internal investigation for the medication error dated 03/27/25 for Resident #89 revealed LPN #309 prepared medication for administration and administered the medication to the wrong resident.
Phone interview on 04/02/25 at 4:32 P.M. with LPN #309 stated she was working on 03/27/25 and was overwhelmed with distractions with a new resident and her family with anxiety and a resident that was sent out by ambulance and she began her medication administration late. LPN #309 stated during her medication administration she misread the room and administered medication to the wrong resident. LPN #309 further stated she administered Oxycodone five milligrams, two pills, a medication for acid reflux and upon entering the room for Resident #89 he requested Tylenol and she returned to the medication cart, obtained the Tylenol and then returned to Resident #89 and administered the medication. LPN #309 stated Resident #89 inquired about the medication, she explained the medication he was receiving and LPN #309 then stated Resident #89 shrugged his shoulders and took the medication. LPN #309 then stated Resident #89 then reported to her immediately after taking the medication those aren't my pills. LPN #309 stated she returned to the medication cart and discovered she administered the wrong medication to the wrong resident.
Interview on 03/31/25 at 5:10 P.M. with the Director of Nursing (DON) identified only one resident with medication errors in the past three months was Resident #89.
Review of the incident and accident log for past three months revealed there was only one resident with medication errors, Resident #89.
Review of the facility policy titled Medication Administration, undated revealed general procedure for medication administration include observation of the five rights in giving medication, the right resident, the right time, the right medication, the right dose, and the right route. Full attention should be given during preparation of medications avoiding distractions is important for infection prevention and reducing errors.
This deficiency represents non-compliance investigated under Complaint Number OH00162741.

Based on review of public social media videos, resident interviews, staff interviews, review of the employee handbook, review of staff schedules, and review of facility policy, the facility failed to ensure residents' right to privacy was honored when State Tested Nurse Aide (STNA) #100 video recorded conversations and interactions with staff and residents (including during personal care) in resident rooms, in common areas, discussed resident care needs and described a resident's malodorous wounds using profanity, while posting the videos to social media and not in accordance with facility policy. This affected four (#13, #31, #62, and #73) of four residents reviewed for privacy and confidentiality. The facility census was 81.
Findings Include:
Review of STNA #100's public social media account revealed three live recorded videos (meaning the video was posted to the social media page as the video was being recorded) taken at the facility involving residents in the privacy of their home. The live recorded videos were dated 12/22/23, 12/25/23 and 12/30/23, with each video lasting between 10 and 16 minutes. Review of the video posted on 12/25/23 revealed STNA #100 speaking with Resident #31. In the video, STNA #100 called Resident #31 by first name and the back of the resident's head was visible on the video. STNA #100 made a comment to Resident #31 about his roommate and an incident that occurred with the roommate the previous night that had nothing to do with the care needs and/or provision of care for Resident #31. Further review revealed STNA #100 describing having to provide care for Resident #73's buttocks (expletive used in the video) wound, adding the wound was malodorous and foul-smelling. Review of the video posted on 12/30/23 revealed STNA #100 discussed care to be provided to Residents #62 and #73, identifying each resident by first name. In addition, the 12/30/23 video revealed STNA #100 entered Resident #13's room. The video went black, but the audio continued to record and STNA #100 and an unknown staff person assisted Resident #13 with personal care. Resident #13 was called by first name and could be heard interacting with the staff during care. The video dated 12/22/23 was deleted prior to being able to fully view the recording.
Interview on 01/09/24 at 9:45 A.M. with the Administrator and the Director of Nursing (DON) verified the videos were taken inside the facility. Each denied knowledge of the videos prior to the interview. The Administrator and DON confirmed the residents named in the videos were facility residents and identified STNA #100 as facility staff. Additionally, the DON verified Resident #73 had a wound, as discussed in the 12/25/23 video.
A follow-up interview on 01/09/24 at approximately 11:10 A.M. with the Administrator confirmed the facility was the residents' home and they should expect privacy within their home, which included not being recorded.
Interviews on 01/09/24 at 2:23 P.M. with Resident #13 and at 2:45 P.M. with Resident #31 revealed each resident denied knowledge of being recorded.
Interview on 01/09/24 at 3:55 P.M. with Resident #73 revealed no knowledge of care needs being discussed on a recorded video (wound care discussed in video dated 12/25/23). Resident #73 indicated he would not be agreeable to having any personal information recorded.
Review of the staff schedules verified STNA #100 was scheduled to work on 12/22/23, 12/25/23 and 12/30/23.
Review of the Employee Handbook, revised July 2015, verified the facility takes no position on the employee's decision to start or maintain a blog or participate in other social networking activities; however, it is the right and duty of the facility to protect itself from unauthorized disclosure of information. In addition, employees may not use their personal cell phones in work areas. The use of cameras (unless job related and approved by the executive director), camera phones, iPods, mp3 players or other electronic devices is not permitted during work hours.
Review of the facility policy titled Ohio Abuse, Neglect and Misappropriation, revised 09/20/22, revealed unauthorized disclosure of resident photographs or images could be mental, physical, or sexual abuse depending on how the images were used.
Review of the facility policy titled Unauthorized Disclosure of Resident Images, revised 10/25/22, revealed the facility provided resident centered care that inhibited employees from taking photos and/or distributing photographs in any fashion including but not limited to posting on social media sites or videos that demean or humiliate a resident.
This deficiency represents non-compliance investigated under Complaint Number OH00149669.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure signage and Personal Protective Equipment (PPE) were posted and available to a COVID-19 positive room. This affected one (Resident #17) of one resident observed for isolation. Additionally, the facility failed to ensure staff took off used PPE and practiced hand hygiene when exiting a COVID-19 positive room. This affected two (Residents #38 and #40) of two residents observed in contact with the staff member. The facility census was 81.
Findings include:
1. Review of Resident #17's medical record revealed an admission date of 08/31/23. Diagnoses included peripheral vascular disease, chronic obstructive pulmonary disease, nicotine dependence, and COVID-19. Resident #17's COVID-19 diagnosis was added 12/08/23.
Review of Resident #17's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #17 was cognitively intact. Resident #17 required set up only for activities of daily living. Resident #17 displayed no behaviors during the review period.
Review of Resident #17's care plan revised 12/08/23 revealed the resident was on droplet isolation due to positive COVID-19 test results on 12/08/23. Interventions were to include arranging supplies and equipment in resident's room, implement droplet isolation precautions, and explain purpose or isolation precautions necessary to resident and family.
Review of Resident #17's physician orders revealed an order dated 12/08/23 for Contact/Droplet Precautions every shift for COVID-19.
Observation on 12/11/23 at 9:34 A.M. of Resident #17's room found red tape along the top and left side of the door. No PPE was available and no signage was posted indicating Resident #17 was on droplet isolation precautions.
Interview on 12/11/23 at 9:37 A.M. with Licensed Practical Nurse (LPN) #121 revealed she was not sure if Resident #17 was still considered positive. She verified there was no signage or PPE outside his room. LPN #121 stated the COVID-19 positive residents typically had signs and PPE available.
Interview on 12/11/23 at 9:39 A.M. with State Tested Nursing Assistant (STNA) #172 revealed he double checked with the unit manager and verified Resident #17 was still on isolation precautions for COVID-19.
Review of the facility policy titled, Criteria for COVID-19 Requirements, revised 05/11/23 revealed appropriate signage was to be placed on or around the resident's room door, full PPE was required when entering the room which was to include N95 mask, eye protection, gown and gloves. Full PPE should be located at or near the entrance of the resident's room.
2. Observation 12/11/23 at 1:33 P.M. revealed the food cart arrived to the 300 hall and staff began passing trays to residents. Business Office Manager (BOM) #183 was observed to put on PPE and entered a COVID positive room with two residents inside (#38 and #40). The STNA passed the trays one at a time to the BOM while she was wearing the PPE (N-95, gown, gloves, and faceshield) in the room. A resident declined his food and requested a sandwhich from the kitchen so BOM informed the STNA who left to go to the kitchen. While waiting, BOM #193 stood in the doorway conversing with staff who walked by including an additional aide, maintenance staff, and a nurse. After several minutes of standing in the doorway, BOM #193 exited the room and removed the faceshield, gown and gloves while keeping the exposed/soiled N-95 on and also did not preform hand hygiene after exiting the room. BOM walked through the hallway by numerous residents at the nurses station, residents sitting in the hallway and sitting by the front desk/lobby area. BOM #183 then walked back to her office where she interacted with staff.
Interview on 12/11/23 at 1:41 P.M. with BOM #183 confirmed she did not properly remove and dispose of a dirty N-95 mask and did not preform hand hygiene. She revealed she was hot and did not even think about it. BOM #183 reported she was supposed to removed the dirty N-95 mask when exiting the room and place a clean mask on while being in the halways and common spaces.
Review of the policy titled, Criteria for COVID-19 Requirements, dated 05/11/23 revealed full PPE was required when entering a residents room including N-95 mask, eye protection, gown and gloves. The PPE should be discarded before exiting the residents room.
This deficiency represents non-compliance investigated under Complaint Number OH00148942.

Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure medications were administered as ordered by the physician, within prescribed time frames, and in accordance with manufacturer instructions for use, resulting in a medication error rate above five percent (%). A total of 10 medication errors were observed out of 43 opportunities for a medication administration error rate of 23.26%. This affected four (Residents #16, #52, #1, #53) of six residents observed during medication administration. The facility census was 81.
Findings include:
1. Review of Resident #16's medical record revealed a physician order dated 11/17/23 for Hydrocodone-Acetaminophen (pain medication) 5-325 milligrams (mg) one tablet four times a day for pain scheduled 9:00 A.M., 12:00 P.M., 6:00 P.M., 9:00 P.M. An order dated 06/22/23 for as needed (PRN) Acetaminophen 325 mg two tablets every six hours for pain.
Observation on 12/12/23 at 7:17 A.M. noted Licensed Practical Nurse (LPN) #121 obtained Resident #16's medications from the medication cart and proceeded to administer to the resident. Observation noted Resident #16 to complain of left leg pain with facial grimacing. LPN #121 obtained a pain rating of 8 from the resident. LPN #121 returned to the medication cart and stated Resident #16 had a current physician order for Hydrocodone-Acetaminophen 5-325 milligrams (mg), however the medication was not available since the previous day and LPN #121 was unable to access the facility in-house supply due to lack of knowledge. At 7:28 A.M., LPN #121 obtained PRN Acetaminophen 325 mg two tablets and returned to Resident #16's room and administered the two tablets.
2. Review of Resident #52's medical record noted a physician order dated 11/26/22 for levetiracetam oral solution 100 mg/milliliters (ml) give 7.5 ml two times daily for seizures. Prescribed times at 8:00 A.M. and 6:00 P.M.
Observation on 12/12/23 at 9:20 A.M. noted Licensed Practical Nurse (LPN) #191 obtaining Resident #52's medications from the medication cart. Medications included levetiracetam oral solution. LPN #52 poured 7.5 milliliters (ml) of solution into a medication cup and proceeded to Resident #52's room. At 9:28 A.M. LPN #191 provided the medication to Resident #52 (approximately an hour and a half late).
3. Review of Resident #53's medical record noted the following physician orders:
12/10/23 Oxycontin extended release 12 Hour Abuse-Deterrent 40 mg two times daily for pain at 9:00 A.M. and 6:00 P.M.
12/06/23 Baclofen 10 mg four times a day for contracture prescribed times 9:00 A.M., 12:00 P.M., 6:00 P.M., 9:00 P.M.
06/15/23 Ipratropium-Albuterol Inhalation Aerosol Solution 20-100 MCG/ACT one puff inhale four times a day for chronic obstructive pulmonary disease prescribed at 8:00 A.M., 12:00 P.M., 4:00 P.M., 8:00 P.M.,
12/10/23 Ativan 0.5 mg every morning (AM) and bedtime (HS) for anxiety
06/16/23 Fluticasone-Salmeterol inhalation aerosol powder breath activated 500-50 mcg/act one inhale every morning and at bedtime for chronic obstructive pulmonary disease given AM and HS
07/19/23 Lyrica 100 mg three times daily for neuropathy at AM, afternoon, and HS
2/06/23 Baclofen 10 mg four times daily for contractures at 9:00 A.M., 12:00 P.M., 6:00 P.M., 9:00 P.M.
Observation on 12/12/23 at 12:10 P.M. noted Resident #53 in bed stating he had not received his morning (AM) medications, including pain medication. Resident #53 did not describe his level of pain at the time.
Interview on 12/12/23 at 12:12 P.M. with LPN #191 confirmed Resident #53 had not received morning medications. LPN #191 proceeded to obtain Resident #53's medications from the medication cart. Medications included the following: Oxycontin extended release 12 Hour Abuse-Deterrent 40 mg, Baclofen 10 mg, Ipratropium-Albuterol Inhalation Aerosol Solution 20-100 mcg/act, Ativan 0.5 mg, and Fluticasone-Salmeterol inhalation aerosol powder breath activated 500-50 mcg/act. At 12:22 P.M. LPN #191 proceeded to administer the AM medications to the resident and confirmed the medications were provided outside of prescribed time frames.
Review of facility's undated Medication Administration policy noted medications are to be administered as prescribed by the provider. Medications will be administered within the time frame of one hour before and up to one hour after time ordered. Always follow manufacturer guidelines for specific medication use. Inhalers direct rinsing mouth after steroid inhaler.
Review of Liberalized Medication Administration undated timeframe's as follows: AM starting at 6:00 A.M. and may extend to 11:00 A.M., Afternoon starting at 12:00 P.M. and may extend to 3:00 P.M., PM starting at 4:00 P.M. and may extend to 7:00 P.M. Any medication ordered by the physician for a specific time will be given at that specific time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, family interview, staff interview, review of the facility contingency box medication list, and review of facility policy, the facility failed to ensure medications were available from the pharmacy for timely administration. In addition, the facility failed to secure available medications from the contingency box for administration when resident's medications were unavailable from the pharmacy. This affected five (#2, #68, #284, #285, #287) of nine residents reviewed for medication administration. The facility census was 81.
Findings included:
1. Review of Resident #2's medical record revealed an admission date of 11/17/23. Diagnoses included pancreatic cancer, antiphospholipid syndrome, fibromyalgia, breast cancer, thrombocytopenia, and hemiplegia/hemiparesis following a cerebral vascular accident.
Review the admission Minimum Data Set (MDS) assessment, dated 11/24/23, revealed Resident #2 had intact cognition. The resident was independent for activities of daily living (ADLs), but required setup or clean-up assistance with eating.
Review of Resident #2's most recent care plan revealed she was at risk for abnormal bleeding or hemorrhage due to anticoagulant/antiplatelet use. Interventions included to provide anticoagulant/antiplatelet medication per medical providers order.
Review of Resident #2's physician order dated 11/17/23 revealed abatacept subcutaneous solution (anti-inflammatory) auto-injector 125 MG/ML (Abatacept) was to be subcutaneously injected in the morning every seven days for inflammation.
Review of Resident #2's Medication Administration Record (MAR) for November 2023 revealed on 11/18/23 and 11/25/23, abatacept subcutaneous solution administration was documented as 9, indicating to see nurses notes.
Review of Resident #2's physician order dated 11/17/23 revealed linaclotide (treatment of irritable bowel) oral capsule 145 micrograms (mcg) was ordered. Directions were to give one capsule by mouth every morning for digestive aide.
Review of Resident #2's November 2023 MAR revealed linaclotide was documented 9 on 11/18/23 and 11/19/23, which indicated to see nurses notes.
Review of Resident #2's physician order dated 11/17/23 revealed Pregabalin (anticonvulsant) oral capsule 75 mg was to be administered every morning and bedtime for health maintenance. The medication was to begin on 11/18/23.
Review of Resident #2's November 2023 MAR revealed it was documented as 9 on 11/18/23 for both doses.
Review of the nursing progress notes from 11/17/23 through 11/19/23 revealed no information related to the reason Resident #2's medications were not administered.
Review of the contingency box (c-box - in house available medication) list revealed Pregabalin was available for nursing staff to pull for administration to Resident #2. There was no evidence Pregabalin was pulled from the c-box for administration.
Interview on 12/11/23 at 2:48 P.M. with Resident #2 revealed the resident failed to receive medications for two days after she was admitted .
2. Review of Resident #68's medical record revealed an admission date of 06/13/23. Diagnoses included acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus, congestive heart failure (CHF), and atrial fibrillation.
Review of the quarterly MDS assessment, dated 10/01/23, revealed Resident #68 required maximum assist for all ADLS, except eating, which she was independent.
Review of Resident #68's medical record revealed a physician's order dated 06/13/23 for Apixaban (anticoagulant) five mg tablet to be administered every morning and bedtime for atrial fibrillation. Additionally, Resident #68 had an order for Diclofenac sodium gel (nonsteroidal anti-inflammatory) external gel 1% to be applied topically to the bilateral knees three times a day for pain.
Review of Resident #68's MAR for December 2023 revealed Apixaban and Diclofenac sodium gel had no documentation for administration on 12/10/23 and 12/11/23, evening doses.
Review of Resident #68's progress notes, from 12/10/23 and 12/11/23, revealed the notes were silent for a reason Apixaban and Diclofenac sodium gel were not administered.
3. Review of Resident #284's medical record revealed an admission date of 12/04/23. Diagnoses included lung cancer metastasized to the bone marrow and bones, kyphosis, anemia, chronic obstructive pulmonary disease, diabetes mellitus, acute respiratory failure, and spine fusion.
Review of the MDS revealed it was in process.
Review of Resident #284's care plan revealed the resident had complaints of acute and chronic pain due to a T-5 fracture, spinal fusion, and lung cancer with metastasized to the bone and bone marrow. Interventions included to provide medication per orders and monitor for side effects and effectiveness of the medication.
Review of Resident #284's physician orders, dated 12/04/23, revealed the following orders: Mirtazapine (antidepressant) oral tablet 30 mg to be given by mouth at bedtime for depression, Montelukast sodium (anti-inflammatory) tablet 10 mg to be administered by mouth at bedtime for allergies, Budesonide-Formoterol Furnarate inhalation aerosol (controls asthma and improves lung function) 160-4.5 microgram (mcg) two puffs inhaled orally every morning and bedtime for wheezing, and Lantus (antidiabetic) SoloStar 100 units per milliliter (ml) solution pen-injector, inject 10 units subcutaneously at bedtime for diabetes mellitus.
Review of Resident #284's MAR for December 2023 revealed on 12/10/23, there was no documentation of administration of the bedtime doses of Mirtazapine, Montelukast sodium, Budesonide-Formoterol Furnarate, and Lantus.
Review of Resident #284's nursing progress notes for 12/10/23 revealed the record was silent as to why the medications were not administered.
Review of the c-box medication list revealed Lantus and Mirtazapine were available for nursing staff to pull for administration to Resident #284. Further review revealed no evidence the medication was pulled for Resident #284.
4. Review of Resident #285's medical record revealed an admission date of 12/08/23. Diagnoses included right femur fracture, multiple sclerosis (MS), asthma, coronary artery disease, lymphedema, and peripheral autonomic disease.
Review of Resident #285's MDS revealed it was in process.
Review of Resident #285's care plan revealed no mention of pain control or medication administration.
Review of Resident #285's physician orders, dated 12/08/23, revealed the resident had the following medication orders: atorvastatin calcium (anticonvulsant) oral tablet 40 mg one time daily at bedtime for hyperlipidemia; calcium carb-cholecalciferol (calcium supplement) oral tablet 600-5 mg/mcg every morning for a supplement; lisinopril (antihypertensive) oral tablet 40 mg every morning for hypertension; metoprolol tartrate (antihypertensive) oral tablet 25 mg to be administered every morning for hypertension; omega-3 oral capsule (Omega-3 Fatty Acids) one by mouth every morning for a supplement; polyethylene glycol 3350 powder 17 grams (gm) by mouth in the morning for constipation; aspirin oral tablet chewable 81 mg to be administered every morning for prophylactic; carbarazepine (anticonvulsant) oral tablet 100 mg every morning and bedtime for convulsions; fluticasone-salmeterol (corticosteroid) inhalation aerosol powder breath activated 250-50 mcg per actuation to be inhaled every morning and at bedtime for shortness of breath and wheezing; glycerin-hypromellose-peg (artificial tears) 400 ophthalmic solution 0.2-0.2-1 % one drop in both eyes every morning and bedtime for dry eyes; levetiracetam oral tablet(anticonvulsant) 500 mg every morning and bedtime for convulsions; senna-docusate sodium (stool softner) tablet 8.6-50 mg every morning and bedtime for constipation; gabapentin (anticonvulsant) oral capsule 300 mg three times a day for health maintenance; and hydrcodone-acetaminophen (opioid pain medication) tablet 5-325 mg one tablet every eight hours as needed for pain rated over six out of 10 for 14 days.
Review of Resident #285's MAR for December 2023 revealed the following:
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On 12/08/23, there was no documentation for atorvastatin administration.
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On 12/09/23, calcium carb-cholecalciferol was documented as 9, which indicated to see nurses notes.
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On 12/09/23, lisinopril was documented as 9.
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On 12/09/23, metoprolol tartrate was documented as 9.
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On 12/09/23, omega-3 was documented as 9.
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On 12/09/23, polyethylene glycol 3350 powder was documented as 9.
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On 12/08/23, there was no documentation for aspirin administration. On 12/09/23, aspirin was documented as 9.
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On 12/08/23 and 12/09/23, carbarazepine was documented 9.
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On 12/08/23, the evening dose of fluticasone-salmeterol was silent for any administration documentation. The 12/09/23 morning dose was documented as 9.
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On 12/08/23 and 12/09/23, glycerin-promellose-peg ophthalmic solution, the MAR was silent for any documentation related to administration.
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On 12/08/23, levetiracetam administration was blank for the bedtime dose. On 12/09/23, 9 was documented for the morning dose.
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The 12/08/23 bedtime dose and 12/09/23 morning dose were both absent of documentation of senna-docusate sodium administration.
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On 12/08/23, gabapentin evening dose was absent for documentation of administration. On 12/09/23, both the morning and afternoon doses were documented as 9.
Review of nursing progress notes from 12/08/23 through 12/09/23 revealed no information related to the reason Resident #285 did not receive medications as ordered.
Review of the c-box medication list revealed atorvastatin calcium, lisinopril, metoprolol tartrate, gabapentin, senna docusate, and levetiracetam were available for nursing staff to removed from the c-box for administration. There was no evidence nursing staff pulled the medications for administration to Resident #285.
Interview on 12/11/23 at 10:32 A.M. with Resident #285 and her family revealed the resident failed to receive her medications for several days after admission. The resident stated she brought her medication with her from her previous facility so there should have been no reason they were not administered.
Interview on 12/14/23 at 7:00 A.M. with Licensed Practical Nurse (LPN) #180 verified Resident #258 was admitted with their own medications but was unaware of why those were not started on admission.
5. Review of Resident #287's medical record revealed an admission date of 12/08/23. Diagnoses included basal cell carcinoma of the scalp and neck, myasthenia gravis, diabetes mellitus, acute respiratory failure. adult failure to thrive, and osteomyelitis.
Review of the MDS assessment revealed it was in process.
Review of Resident #287's care plan revealed the resident had complaints of acute/chronic pain. Interventions were to follow physician orders for complaint of pain.
Review of current physician orders revealed Resident #287 had the following medication orders: gabapentin 100 mg three times a day for health maintenance/neuropathy; Ketonconazole external cream (antifungal) 2% topically daily for a rash until 12/23/23; Lovenox (enoxaparin - anticoagulant) injection 40 mg/ml every 24 hours for circulation; pyridostigmine bromide (treatment for underactive bladder) tablet 60 mg, one and one half tablets every four hours for health maintenance; morphine sulfate ER (opioid) 15 mg twice daily for pain; and Bactrim DS (antibiotic) 800-160 mg Monday, Wednesday and Friday for prophylaxis.
Review of the MAR for December 2023 revealed the following:
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The afternoon dose on 12/08/23 and the morning and afternoon doses on 12/09/23 of gabapentin were silent for administration documentation.
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On 12/08/23, the MAR reflected no documentation related to the administration of Bactrim.
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On 12/08/23, pyridostigmine bromide administration was documented as 9 at 1:00 A.M. and 5:00 A.M. and the 1:00 P.M. and 5:00 P.M. doses had no documentation related to administration. Additionally, the 12/10/23 8:00 P.M. dose and the 12/11/23 12:00 A.M. and 4:00 A.M. doses revealed no documentation of administration.
•
On 12/09/23, no documentation was present for Ketonconazole administration.
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On 12/10/23, enoxaparin injection was documented as 9.
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Morphine Sulfate was documented as 9 for the morning and evening doses on 12/10/23 and the 12/11/23 morning dose.
Further review of nursing progress notes from 12/08/23 through 12/11/23 revealed no documentation related to the reason Resident #287 did not receive medications as ordered.
Interview on 12/13/23 at 11:30 A.M. with Registered Nurse (RN) #178 revealed it usually took one to two days to receive ordered medications from their pharmacy, which was located out of town.
Interview on 12/14/23 at 6:58 A.M. with Licensed Practical Nurse (LPN) #180 revealed it took one to two days to receive medications from the pharmacy when a resident was admitted . She was unaware of why the medications were not pulled from the back-up contingent box when available and needed.
Interview on 12/14/23 at 9:00 A.M. with the Director of Nursing (DON) revealed, upon admission on [DATE], Resident #285 had all ordered medications with her. The DON confirmed the MAR indicated Resident #285's medications were not administered as ordered and she was unaware of why the medications were not administered. Additionally, the DON verified Residents #2, #68, #284 and #287 did not receive medications as ordered. The DON stated it generally took one to two days for medications to arrive from the pharmacy once ordered. While some of the missed medications were available in the facility's c-box, the DON confirmed nursing staff did not pull medications, as available, to administer to Residents #2, #68, #284 and #287.
Review of the facility policy titled Medication Administration, undated, revealed the facility will proved resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure interventions were implemented to timely address bowel incontinence and related indwelling urinary catheter malfunction. This affected one (#53) of two residents reviewed for incontinence and catheter care. The facility census was 81.
Findings include:
Resident #53 admitted to the facility on [DATE] with diagnoses including osteomyelitis, stage IV pressure ulcer to left buttock, left hip, right hip, right heel, sacral region, venous insufficiency, type II diabetes mellitus, chronic obstructive pulmonary disease, schizoaffective disorder, chronic pain, contracture left hip, right hip, left knee, major depression, and anxiety disorder.
Review of the Minimum Data Set (MDS) assessment, dated 11/11/23, revealed Resident #53 was cognitively intact, dependent on staff for activities of daily living (ADLs), utilized an indwelling catheter, was incontinent of bowel, and admitted with four stage IV pressure ulcers and had one in-house acquired pressure ulcer.
Review of the plan of care, dated 07/12/23, revealed Resident #53 had bowel incontinence due to immobility and paraplegia. Interventions included provide assistance with toileting as needed, provide peri-care after each incontinence episode, observe for alterations in skin integrity status, and notify medical provider, resident/resident representative of abnormal findings as needed. Further review revealed Resident #53 had a supra pubic indwelling catheter related to impaired skin integrity, obstruction uropathy, and benign prostatic hypertrophy. Interventions included change catheter per medical provider order, and as needed (PRN), enhanced barrier precautions when dressing/bathing/showering/transferring/personal hygiene, changing linens, toileting and peri-care, providing care to urinary catheter, observe /record/report to physician (MD) for signs or symptoms (s/sx) of urinary tract infection (UTI), observe for s/sx of discomfort on urination and frequency, position catheter bag and tubing below the level of the bladder and provide privacy bag, secure catheter to the leg with security device, provide catheter care every shift and PRN, and notify medical provider if urine is of abnormal color, consistency, or odor. Additionally, the plan of care was revised on 11/13/23 to include Resident #53 had a behavior problem related to diagnoses of schizophrenia, anxiety, depression, panic disorder, loss of independence, nursing home admission, pain, and psychosocial issues. Resident #53 refused to have sheets changed, refused to have wound dressing changed, refused to have nails trimmed, scratched self, digs at back side with his nails, throws food trays on the floor and/or at staff, scratched staff when providing care, combative with cares that are being given, refused to turn and repositioned, put hands in stool, preferred to wear gown, refused respiratory medications, refused to get up out of bed, refused to off load heels, refused care and dressing changes. Interventions included administer medications as ordered, approach, speak in calm manor, encourage active support by family/resident representatives, encourage resident to express feelings, encourage to maintain as much independence and control/decision making as possible, intervene as necessary to protect the rights and safety of others, minimize potential for disruptive behaviors by offering tasks that divert attention, monitor behavioral episodes, and attempt to determine underlying causes, observe and anticipate resident's needs: thirst, food, body positioning, pain, toileting needs and praise any indication of progress in behaviors.
Observation on 12/13/23 at 6:10 A.M. with Licensed Practical Nurse (LPN) #124 revealed Resident #53 in bed. Upon entrance to the room, a pervasive odor was noted. Resident #53 was heavily soiled with liquid stool and urine. Additional observation noted Resident #53's hospital gown soiled to middle chest.
Observation on 12/13/23 at 6:12 A.M. revealed LPN #101 and State Tested Nurse Aide (STNA) #112 obtained supplies and proceeded to provide incontinence care to Resident #53, including a bed bath, clothing change and bed linen change. Throughout the observation, Resident #53's urinary indwelling supra-pubic catheter was noted to be leaking from the stoma. A heavily soiled stoma dressing was removed and the urinary catheter drainage collection bag was empty.
Interview on 12/13/23 at 6:32 A.M. with STNA #112 confirmed she provided care to Resident #53 on the night shift, from 10:30 P.M. until 6:30 A.M. STNA #53 stated the resident was last checked at 5:00 A.M. and refused incontinence care or repositioning during the entire shift. STNA #112 stated she notified LPN #176 and no additional interventions or strategies had been attempted to address the residents incontinence or repositioning needs. Furthermore, STNA #112 verified the urinary catheter collection bag did not collect urine during the shift and remained empty.
Interview on 12/13/23 at 6:36 A.M. with LPN #176 confirmed she was assigned to provide care to Resident #53 during the night shift, between 6:30 P.M. and 7:00 A.M. LPN #176 revealed she was unaware Resident #53 would not allow incontinence care or repositioning throughout the shift. LPN #176 indicated Resident #53 would respond to her regarding turning, repositioning and incontinence care; however, LPN #176 was not informed of the refusals or the need for intervention. LPN #176 verified she was aware Resident #53's urinary catheter drainage collection bag was not collecting urine at the beginning of her shift and she was going to notify the on-coming day shift nurse for further intervention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, resident interview, review of the air mattress user manual, and review of facility policy, the facility failed to ensure interventions were consistently implemented to promote skin integrity. This affected one (#53) of three residents reviewed for pressure ulcers. The facility census 81.
Findings include:
Resident #53 admitted to the facility on [DATE] with the diagnoses including osteomyelitis, stage IV pressure ulcer to left buttock, left hip, right hip, right heel, and sacral region, venous insufficiency, type II diabetes mellitus, chronic obstructive pulmonary disease, schizoaffective disorder, chronic pain, contracture left hip, right hip, and left knee, major depression, and anxiety disorder.
Review of the Minimum Data Set (MDS) assessment, dated 11/11/23, revealed Resident #53 was cognitively intact, dependent on staff for activities of daily living (ADLs), had an indwelling catheter, was incontinent of bowel, and admitted with four stage IV pressure ulcers and had one in-house acquired pressure ulcer.
Review of the plan of care, revised 11/09/23, revealed Resident #53 had impaired skin integrity and was at risk for altered skin integrity due to immobility, poor nutrition, poor vascularity, and pressure ulcers. Interventions included administer medications as ordered, monitor for side effects and effectiveness, administer treatments as ordered by medical provider, ankle lift pillows as tolerated, apply appropriate pressure reducing appliances, apply barrier creams post incontinent episodes, complete skin at risk assessment upon admission/readmission, quarterly, and as needed, complete weekly skin checks, educate resident/resident representative on need for turning and repositioning, enhanced barrier precautions when dressing/bathing/showering/transferring/personal hygiene, changing linens, toileting and peri-care, providing care to wound care for skin openings that require a dressing, ensure residents are turned and repositioned, evaluate existing wound daily for changes (redness, edema, drainage, pain, foul odor), keep gerichair close to resident room and encourage use up to daily as tolerated, monitor meal intake, monitor vital signs, notify resident/resident representative, medical provider of any decline in wound healing, nutritional consult on admission, quarterly, and as needed (PRN), offer dietary supplements per medical provider's orders, provide diet as ordered, and provide peri-care as needed to avoid skin breakdown due to incontinence.
Review of a physician order dated 11/10/23 revealed Resident #53 was ordered an Alternating Pressure Mattress (APM) to the bed and to check placement, function, and settings according to manufacturer instructions.
Additional review of the plan of care, revised 11/13/23, revealed Resident #53 had a behavior problem related to diagnoses of schizophrenia, anxiety, depression, panic disorder, loss of independence, nursing home admission, pain, and psychosocial issues. Resident #53 smoked in his room, refused to have sheets changed, refused to have wound dressing changed, refused to have nails trimmed, scratched self, digs at back side with his nails, throws food trays on the floor and/or at staff, scratched staff when providing care, combative with cares that are being given, refused to turn and reposition, put hands in stool, preferred to wear gowns, refused respiratory medications, refused to get up out of bed, and refused to off load heels. Interventions included administer medications as ordered, educate resident and resident representative to medication effectiveness and side effects, approach, speak in calm manor, encourage active support by family/resident representatives, encourage resident to express feelings, encourage to maintain as much independence and control/decision making as possible, intervene as necessary to protect the rights and safety of others, minimize potential for disruptive behaviors by offering tasks that divert attention, monitor behavioral episodes, and attempt to determine underlying causes, observe and anticipate resident's needs: thirst, food, body positioning, pain, toileting needs, and praise any indication of progress in behaviors.
Review of a weight, dated 12/06/23 and located in the electronic medical record, revealed Resident #53 weighed 127.2 pounds (lbs).
Observation on 12/13/23 at 6:10 A.M. with Licensed Practical Nurse (LPN) #124 revealed Resident #53 in bed. Upon entrance to the room, a pervasive odor was noted. Resident #53 was heavily soiled with liquid stool and urine. Continued observation revealed Resident #53's hospital gown was soiled to middle chest. An air mattress was in use to the bed, with the low pressure indicator light flashing. The air mattress weight was set at 260 pounds.
Observation on 12/13/23 at 6:12 A.M. revealed LPN #101 and State Tested Nurse Aide (STNA) #112 obtained supplies and proceeded to provide incontinence care to Resident #53, including a bed bath, clothing change and bed linen change. Resident #53 was noted to have food debris under him, a heavily soiled adult incontinence brief, and a stage IV pressure ulcer dressing heavily soiled and dislodged, with wound packing dangling from the wound.
Interview on 12/13/23 at 6:32 A.M. with STNA #112 revealed she was responsible for providing care to Resident #53 during the night shift, from 10:30 P.M. to 6:30 A.M. STNA #53 revealed the resident was last checked at 5:00 A.M. and refused incontinence care and repositioning during the entire shift. STNA #112 stated she notified LPN #176 and no additional interventions or strategies had been attempted to address the resident's incontinence or repositioning needs.
Interview on 12/13/23 at 6:36 A.M. with LPN #176 confirmed she had been assigned to Resident #53's care during the night shift, between 6:30 P.M. and 7:00 A.M. LPN #176 stated she was unaware Resident #53 would not allow incontinence care or repositioning throughout the shift. LPN #176 indicated Resident #53 would respond to her regarding turning, repositioning and incontinence care; however, LPN #176 denied being informed of the refusals or the need for intervention.
Interview on 12/13/23 at 7:35 A.M. with wound specialist, Certified Nurse Practitioner (CNP) #1, during treatment observation, revealed Resident #53 had multiple pressure ulcers. CNP #1 stated Resident #53 frequently refused treatments and repositioning. The resident had been given education and encouragement to comply with wound treatment. CNP #1 stated Resident #53 agreed to having wounds treated once daily instead of twice daily. Further observation with CNP #1 and LPNs #101, and #124, during pressure ulcer wound evaluation, noted the following wounds: right hip pressure Stage IV measuring 6.8 centimeters (cm) long x 5 cm wide x 0.4 cm deep; right heel pressure Stage IV measuring 6.9 cm x 7 cm x 0.2 cm; sacrum pressure Stage IV measuring 4.5 cm x 4.9 cm x 1.9 cm; left hip pressure Stage IV measuring 0.4 cm x 0.8 cm x 0.1 cm; right medial lower leg pressure Stage IV measuring 13 cm x 6.7 cm x 0.4 cm; left hip distal pressure Stage IV measuring 8 cm x 5.9 cm x 1.2 cm; and left lateral foot pressure Stage IV measuring 1.5 cm x 1.4 cm x 0.2 cm. The bed air mattress was observed to be flashing low pressure and the weight setting was at 260 lbs.
Additional observations on 12/13/23 at 11:39 A.M. and 3:20 P.M. revealed Resident #53 in bed with the air mattress control indicator light flashing low pressure and the weight setting at 260 pounds. Resident #53 was positioned on his back and lying in hole in the mattress, with limited support. Concurrent interview with Resident #53 confirmed he felt like he was sinking into the mattress and this was not comfortable.
Interview on 12/13/23 at 3:27 P.M. with LPN #101, unit manager, revealed the facility did not have access to the air mattress instructions for use due to being supplied by the hospice agency. The facility was contacting the hospice agency for access to the instruction manual.
Review of alternating air mattress user manual noted the manual should be used for initial set up of the system and for reference purposes. Further review revealed to turn the pressure adjust knob to set a comfortable level by using the weight scale as a guide. The low pressure indicator notes a visible indicator (yellow or red) and warns the pressure is below a preset or user-defined level. The visible alarm indicator will continue to flash until the air pressure issue was corrected. Once corrected, the alarm function will automatically reset.
Interview on 12/13/23 at 3:24 P.M. with LPN #153 revealed she was unaware Resident #53 air mattress was not set at the proper weight setting and unaware the air mattress was flashing low pressure since assuming the shift.
Review of facility policy titled Skin Care and Wound Management Overview, undated, revealed the policy was to prevent skin impairment and promote healing of existing wounds. Additionally, a plan of care would be developed with individualized interventions to address risk factors, risk factors and interventions would be communicated to the care giving team, and evaluate for consistent implementation of interventions and effectiveness at clinical meeting.

Based on observation, medical records review, staff interview and review of facility policy, the facility failed to timely notify the physician of a malfunctioning catheter. This affected one (#53) of one residents reviewed for catheter care. The facility census was 81.
Findings include:
Review of Resident #53's medical record revealed an admission date of 06/15/23. Diagnoses included osteomyelitis, stage IV pressure ulcer to left buttock, left hip, right hip, right heel, sacral region, venous insufficiency, type II diabetes mellitus, COPD, schizoaffective disorder, chronic pain, contracture left hip, right hip, left knee, major depression, and anxiety disorder.
Review of the MDS assessment, dated 11/11/23, Resident #53 was cognitively intact. dependent on staff for activities of daily living (ADLs), including bed mobility, had an indwelling catheter, was incontinent of bowel, and admitted with four stage IV pressure ulcers and one in-house acquired pressure ulcer.
Review of the plan of care, revised 07/12/23, revealed Resident #53 had a supra pubic indwelling catheter related to impaired skin integrity, obstruction uropathy, and benign prostatic hypertrophy. Interventions included change catheter per medical provider order, and as needed (PRN), enhanced barrier precautions when dressing/bathing/showering/transferring/personal hygiene, changing linens, toileting and peri-care, and providing care to urinary catheter, observe /record/report to physician (MD) signs or symptoms (s/sx) of urinary tract infection (UTI), observe for s/sx of discomfort on urination and frequency, position catheter bag and tubing below the level of the bladder and provide privacy bag, secure catheter to the leg with security device, provide catheter care every shift and PRN, and notify medical provider if urine is of abnormal color, consistency, or odor.
Observation on 12/13/23 at 6:10 A.M., with Licensed Practical Nurse (LPN) #124, revealed Resident #53 in bed. Entry to the room revealed a pervasive odor. Further observation revealed Resident #53 was heavily soiled with liquid stool and urine and the resident's gown was soiled to middle chest.
Continued observation on 12/13/23 at 6:12 A.M. revealed LPN #101 and State Tested Nurse Aide (STNA) #112 obtain supplies and proceeded to provide incontinence care to Resident #53, including a bed bath, clothing change and bed linen change. Throughout the observation, Resident #53's urinary indwelling supra-pubic catheter was noted to be leaking from the stoma, with a soiled dressing removed by LPN #101. Additionally, LPN #101 removed a heavily soiled adult incontinence brief and the urinary catheter drainage collection bag was empty.
Interview on 12/13/23 at 6:32 A.M. with STNA #112 confirmed she was responsible for Resident #53's care during the night shift, from 10:30 P.M. until 6:30 A.M. STNA #112 stated Resident #53 was last checked at 5:00 A.M. and refused incontinence care or repositioning the entire shift. STNA #112 stated she notified LPN #176 the urinary catheter drainage collection bag was not collecting urine.
Interview on 12/13/23 at 6:36 A.M. with LPN #176 revealed she was responsible for Resident #53's care from 6:30 P.M. until 7:00 A.M. LPN #176 verified she was aware Resident #53's urinary catheter drainage collection bag was not collecting urine at the beginning of the shift and she was going to notify the on-coming day shift nurse for further intervention.
Review of facility policy titled Notification of Change in Condition, undated, revealed the facility must consult with the resident's physician when there is a change requiring such notification, including circumstances requiring the need to alter treatment, or implement new treatment.

Based on observation, resident interview, staff interview, and facility policy review revealed the facility failed to ensure residents lighting was in working condition and within reach. This affected one (#287) of one residents reviewed for accommodation of needs. The facility census was 81.
Findings include:
Review of Resident #287's medical record revealed an admission date of 12/08/23. Diagnosis included basal cell carcinoma of the scalp and neck, myasthenia gravis, diabetes mellitus, acute respiratory failure, adult failure to thrive, and osteomyelitis.
Review of the Minimum Data Set (MDS) revealed it was in process.
Review of Resident #287's care plan revealed the resident had complaints of acute/chronic pain. Interventions were to follow physician orders for complaint of pain.
Observation on 12/11/23 at 3:24 P.M. revealed Resident #287 was lying in bed in a brightly lit room. The resident was unable to reach the wall switches to be able to control the ceiling light nor the overhead bed light. Observation of the bedside lamp revealed it was out of reach and did not contain a light bulb.
Interview with Resident #287 on 12/11/23 at 3:25 P.M. revealed he was unable to reach the lights and had to call for assistance to shut off or turn on the lights. Often times he had to sleep with the lights in the on position.
Interview on 12/11/23 at 3:27 P.M. with Maintenance Technician (MT) #187 verified Resident #287 was unable to reach the light switches for the overhead bed light, ceiling lights, or bedside lamp. Additionally, MT #187 confirmed the bedside lamp did not have a light bulb.
Review of the facility policy titled Resident Rights, undated, revealed it was the policy of the facility to provide a resident centered care that meets the psychosocial, physical and emotional needs and concerns of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review and staff interviews, the facility failed to ensure a resident was free from significant medication error, when insulin orders were erroneously discontinued from the medication record. This affected one (#2) of three residents reviewed for medication administration. The current census is 78.
Findings include:
Record review of Resident #2 revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Diagnoses for Resident #2 included cerebral edema, bipolar disorder, diabetes, heart failure, and morbid obesity.
Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and was a two-person assist for Activities of Daily (ADL). Resident #2 received 3 insulin injections out of 7 days in the review period. Per the assessment there were 0 times the physician changed the order for the insulin. The assessment was documented as signed on 09/19/23 after the 09/13/23 discharge.
1. Review of Resident #2's physician orders from the hospital dated 09/08/23 revealed the resident was ordered Glargine 25 units subcutaneous (SQ) every morning for diabetes.
Review of the medication administration record (MAR) for September 2023 revealed an order dated 09/09/23 at 7:00 A.M. for Glargine (long-acting insulin) 25 units SQ every morning. The medications were not signed off as being administered. The medication then was discontinued at 1:22 P.M. per therapeutic exchange.
Review of a pharmacy therapeutic exchange dated 09/09/23 revealed Pharmacy Note: Therapeutic interchange/substitution - a modification of product to preferred product choice. Lantus for Glargine.
Review of the MAR for September 2023 revealed an entry for Lantus 25 units SQ every morning dated 09/11/23 at 7:00 A.M. This was the first dose of a long-acting insulin the resident received since admission.
2. Review of Resident #2's physician orders from the hospital dated 09/08/23 revealed the resident was ordered to have blood glucose checked three times a day at meals, administer Lispro insulin on a sliding scale with blood glucose 0 - 200 give 0 units, 200- 250 give 8 units, 250 - 300 give 12 units and with a parameter if over 300 give 16 units, with meals for diabetes.
Review of the MAR for September 2023 revealed an entry dated 09/09/23 at 8:00 A.M., for Lispro Insulin (short acting) inject per sliding scale: with blood glucose 0 - 200 give 0 units, 201- 250 give 8 units, 251 - 300 give 12 units and with a parameter if over 300 give 16 units, with meals for diabetes. The insulin was discontinued on 09/09/23 at 1:22 P.M. per therapeutic exchange.
Review of a pharmacy therapeutic exchange dated 09/09/23 revealed Pharmacy Note: Therapeutic interchange/substitution - a modification of product to preferred product choice. Humalog for Lispro.
Review of the MAR for September 2023 revealed an entry dated 09/12/23 at 2:00 P.M., for Humalog Insulin inject per sliding scale: with blood glucose 0 - 200 give 0 units, 201- 250 give 8 units, 251 - 300 give 12 units and with a parameter if over 300 give 16 units, with meals for diabetes.
Review of Resident #2's vital signs revealed only two results for the blood glucoses were documented on 09/09/23 at 7:24 A.M. of 167, and at 12:02 P.M. of 300. No other blood glucose results were documented in the record.
Review of Resident #2's Medication Administration Record (MAR) dated 09/09/23 to 09/13/23 revealed the resident received 12 units of insulin Lispro per sliding scale for a blood glucose of 300 on 09/09/23 at 12:00 P.M. No other doses of Humalog insulin were documented as given per order.
Review of Resident #2's progress notes dated 09/12/23 at 4:00 P.M., revealed the nurse documented the resident refused to have her blood glucose monitored. No other refusals were documented in the progress notes or MAR for the insulin or blood glucose monitoring. No notification to the physician of resident refusals of insulin were noted in the records.
Interview on 10/05/23 at 11:18 A.M., with Licensed Practical Nurse (LPN) #200 revealed the nurse could not recall specifics regarding Resident #2's care. LPN #200 did state any refused medications, including blood glucose monitoring is to be documented in the computer immediately after the resident refused. LPN #200 stated if Resident #2 had an order to monitor the blood glucose or administer insulin during her shift and refused, the nurse would have documented the refusal in the progress notes.
Interview on 10/05/23 at 11:25 A.M., with the Director of Nursing (DON) verified there were admission orders dated 09/09/23 for Resident #2's blood glucose monitoring and insulin medications. The DON verified the resident received the Lantus insulin on 09/11/23 and 09/12/23 per order. Per the DON, the insulin was on the admission order for coverage of blood sugars with Lispro and to receive daily Glargine insulin. The DON stated the pharmacy completed two therapeutic exchanges for the Lispro and the Glargine on 09/09/23. The new therapeutic exchanged insulins were mistakenly not added to the MAR until 09/11/23 for the long acting and 09/12/23 for the short acting insulins. The DON verified the first dose of the long acting was not administered until 09/11/23 and had missed the 09/09/23 and 09/10/23 dose. The DON also verified the resident was not having the blood sugars monitored per the physician orders due to the Lispro being stopped on 09/09/23 and the Humalog being added until 09/12/23. So, the resident was not receiving any insulin due to no blood sugars being checked. The DON stated an offsite corporate nurse enters all physician orders into the medical profiles for the residents and they are to be verified by the unit nurses when residents are admitted . The DON stated the resident did have a behavior of refusing treatments and medications during her short stay at the facility and stated it was procedure to document all refusals in the progress notes.
Review of the policy titled Medication Administration, with review date of 05/29/19, revealed medications would be administered as ordered. Medications that are refused or withheld or not given will be documented. Critical medications, such as insulin, that are refused shall be followed up with physician notification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the medical record, and review of policy, the facility failed to ensure the functioning of wandering devices to prevent elopement was monitored. This affected two (#30 and #31) of two residents reviewed for wandering devices. Additionally, the facility failed to ensure hot water temperatures did not exceed 120 degrees Fahrenheit (F). This affected two (#11 and #115) of seven residents reviewed for hot water temperatures. The facility census was 78.
Findings include:
1. Review of Resident #30's medical record revealed an admission date of 06/27/17, with a diagnosis of dementia.
Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had impaired cognition.
Review of a physician order dated 11/17/22 revealed Resident #30 required staff to check the function of his wandering device on day and night shifts.
Review of the Treatment Administration Record (TAR) for the evening shift on 09/02/23 revealed Licensed Practical Nurse (LPN) #252 checked the function on Resident #30's wandering device.
Interview on 09/05/23 at 9:28 A.M., with LPN #252 revealed she had residents on her hall with a wandering device but could not identify them at that time.
Follow-up interview and observation on 09/05/23 at 2:31 P.M., with LPN #252 revealed she checked the placement of Resident #30's wandering device on his left ankle. Further interview at that time with LPN #252 revealed she performed no additional tasks other than verifying placement when monitoring residents with a wandering device. LPN #252 revealed the functioning of the device was checked by maintenance or the on-call manager. LPN #252 confirmed she documented on Resident #30's TAR on 09/02/23 that she checked the functioning of his wandering device. LPN #252 stated the maintenance person and the on-call manager do not have access to the orders, she had to complete for Resident #30, so she documented the task was completed.
Interview on 09/05/23 at approximately 3:25 P.M., with Unit Manager (UM) #201 informed the surveyor, LPN #252 was knowledgeable about when and how to check the functionality of wandering devices on residents' ankles at bedside and LPN #252 misunderstood the surveyor's question. UM #201 further stated maintenance, or the on-call manager checked the functioning of the doors in response to the wandering device, but nurses were responsible for checking the functionality of the wandering device on each resident's ankle.
Interview on 09/05/23 at approximately 3:27 P.M., with LPN #252 revealed the functionality of the wandering device on each resident's ankle was checked by the maintenance.
2. Review of the medical record for Resident #31 revealed an admission date of 04/29/14, with diagnoses of type 2 diabetes mellitus and Alzheimer's disease.
Review of the quarterly MDS assessment dated [DATE] revealed Resident #31 had impaired cognition and did not exhibit any wandering behavior.
Review of the physician orders for Resident #31 revealed no order to check the functionality of his wandering device.
Interview on 09/06/23 at 2:44 P.M., with the Director of Nursing confirmed Resident #31 had no order to check the functionality of his wandering device.
Review of the undated policy titled Wander Bracelet revealed wander bracelets would be checked for proper functioning daily using the function tester and documented on the TAR.
3. Observation and interview on 09/05/23 at approximately 3:50 P.M. with Maintenance Technician #273 confirmed the bathroom sink temperature was 128 degrees Fahrenheit in the bathroom shared by Resident #11 and Resident #115.
Interview on 09/07/23 at approximately 1:30 P.M., with the Administrator confirmed water temperatures in the facility should be no higher than 120 degrees Fahrenheit.
This deficiency represents non-compliance investigated under Complaint Number OH00145743.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the resident medical records, facility documentation of Ombudsman notification, and staff interview, the facility failed to ensure required notification to the Ombudsman's office. This affected three (#58, #60, and #101) of three resident records reviewed. The facility census was 78.
Findings include:
1. Review Resident #58's medical record revealed an admission date of 07/27/22, with diagnoses including: nontraumatic subarachnoid hemorrhage, chronic obstructive pulmonary disease, type two diabetes mellitus without complication, dysphagia oropharyngeal neuromuscular dysfunction of bladder, essential primary hypertension, schizophrenia, hyperlipidemia, and adjustment disorder with mixed anxiety and depressed mood.
Review of the Minimum Data Set (MDS) assessment, dated 08/02/23, revealed the resident was moderately cognitively impaired.
Review of the census documentation revealed Resident #58 was hospitalized overnight from 07/23/23 to 07/24/23.
2. Review of Resident #60's medical record revealed an admission date of 03/18/23, with diagnoses including: chronic obstructive pulmonary disease, bradycardia, type two diabetes mellitus without complications, paroxysmal atrial fibrillation, essential primary hypertension, muscle weakness, and cognitive communication deficit.
Review of the MDS assessment, dated 07/20/23, revealed an entry assessment was completed.
Review of the census documentation revealed Resident #60 was hospitalized from [DATE] to 07/20/23.
3. Review of Resident #101 closed medical record revealed an admission date of 06/30/23 and discharged on 07/27/23. Diagnosis for Resident #101 included cerebral infarction due to unspecified occlusion or stenosis of unspecified middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified dementia mild with anxiety, hypertensive heart disease with heart failure, hypothyroidism, hyperlipidemia, dysphagia, chronic systolic congestive heart failure, xerosis cutis.
Review of the MDS assessment, dated 07/27/23, revealed the resident was severely cognitively impaired.
Review of the census documentation revealed Resident #101 was hospitalized from [DATE] and returned to the facility on [DATE].
Review of Ombudsman notification documentation, dated July 2023, revealed Resident #58, Resident #60, and Resident #101 were not included on the transfer/discharge notification.
Interview on 09/07/23 at 2:11 P.M., with Social Services #200 verified hospitalization records did not pull in the report and Resident #58, Resident #60, and Resident #101 were not included in the notification of transfers and discharges to the Ombudsman's office.
This deficiency represents non-compliance investigated under Complaint Number OH00145743.

Based on review of the medical record review, staff interview, and review of policy, the facility failed to ensure the comprehensive care plan included discharge planning. This affected two (#8 and #9) of three former residents reviewed for discharge care plans. The facility census was 78.
Findings include:
1. Review of Resident #8's closed medical record revealed an admission date of 04/26/23 and discharged on 08/23/23. Diagnoses for Resident #8 included pulmonary hypertension, type two diabetes mellitus with hyperglycemia, hypoxemia, heart disease, essential (primary) hypertension, hypothyroidism, and hyperlipidemia.
Review of the Minimum Data Set (MDS) assessment, dated 08/23/23, revealed a discharge assessment was completed.
Review of the care plan, initiated on 05/02/23 and closed on 09/05/23, revealed Resident #8's care plan did not include a discharge goal.
2. Review of Resident #9's closed medical record revealed an admission date of 03/07/23 and discharged on 08/24/23. Diagnoses for Resident #9 included muscle wasting and atrophy, interstitial pulmonary disease, ulcerative proctitis without complications, end stage renal disease, type two diabetes mellitus, acquired absence of left leg below knee, essential hypertension, polyneuropathy, hyperparathyroidism, and hyperkalemia.
Review of the MDS assessment, dated 08/24/23, revealed a discharge assessment was completed.
Review of the care plan, initiated on 03/12/23, revealed Resident #9's care plan did not include a discharge goal.
Interview on 09/06/23 at 10:40 A.M., with the Director of Nursing (DON) verified Resident #8 and Resident #9's care plans did not include a discharge goal.
Review of the policy titled, Plan of Care Overview, with review date of 05/01/22, revealed the facility will provide resident centered care and person-centered care planning including goals to potentially return to a community setting.
This deficiency represents non-compliance investigated under Complaint Number OH00145743.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medication insert review, and policy review, the facility failed to ensure medications were administered timely and per manufacturer recommendations. This affected two residents (#17 and #40) of three residents observed for medication administration. The facility census was 78.
Findings included:
1. Review of Resident #40's medical record revealed an admission date of 06/29/20, with diagnoses including asthma, spina bifida, and seasonal allergies.
Review of Resident #40's quarterly Minimum Data Set (MDS), dated [DATE], revealed he had an intact cognition and required one person supervision for eating.
Review of Resident #40's most recent care plan revealed he had an alteration in respiratory status related to asthma. Interventions were to administer medications per medical provider's orders and observe for side effects and effectiveness.
Review of Resident #40's medical record revealed a physician's order dated 06/28/23 for Advair Diskus (steroid and bronchodilator) 250-50 micrograms aerosol powder, breath activated. Administer one puff inhalation orally two times a day for shortness of breath and wheezing due to asthma.
Observation on 09/06/23 at 7:36 A.M. revealed Licensed Practical Nurse (LPN) #253 handed the Advair Inhaler to Resident #40 in which he completed one inhalation. The nurse then took the inhaler and placed it back into the medication cart drawer.
Interview on 09/06/23 at 7:43 A.M., with LPN #253 verified Resident #40 failed to be given proper direction to swish and rinse after administering the Advair Inhaler because the nurse felt it was not required.
Review of the packet insert revealed Advair Diskus should be administered as one inhalation twice daily by the orally inhaled route only. After inhalation, the patient should rinse his/her mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis.
Review of the policy titled Medication Administration, with review date of 05/29/19, revealed to rinse mouth after administering an inhaler containing steroids.
2. Review of Resident #17's medical record revealed an admission date of 01/12/23, with diagnoses including osteoarthritis, convulsions, acute cystitis, and Menier's disease
Review of Resident #17's quarterly MDS dated [DATE] revealed the resident was cognitively intact. She was independent but required some supervision for activities of daily living.
Review of Resident #17's most recent care plan revealed the resident had complaints of acute and chronic pain due to osteoarthritis. Interventions were to provide medication per physician orders, monitor for side effects, and evaluation effectiveness. The resident also suffered from chronic urinary tract infections.
Review of Resident #17's medical record revealed a physician's order dated 01/18/23 to apply Voltaren External Gel (pain reliever) 1% externally to both knees topically every six hours for pain.
Review of Resident #17's Medication Administration Record (MAR) dated July 2023 revealed the resident failed to be administered the Voltaren Gel on 07/17/23 and 07/22/23 at 6:00 A.M.
Review of Resident #17's MAR dated August 2023 revealed the resident failed to receive the gel on 08/04/23, 08/18/23, 08/23/23, 08/26/23, 08/27/23, 08/28/23, and 08/29/23 at 6:00 A.M. per orders. In addition, she failed to receive the medication on 08/23/23 and 08/29/23 at midnight.
Review of Resident #17's MAR dated September 2023 revealed the resident failed to receive the Voltaren Gel on 09/01/23 and 09/02/23 at 6:00 A.M. and on 09/05/23 at midnight.
Review of Resident #17's medical record revealed a physician's order dated 09/02/23 for Ciprofloxacin HCI (antibiotic) oral tablet 250 milligram to be administered by mouth twice daily to treat a urinary tract infection for three days.
Review of Resident #17's September 2023 MAR revealed the resident was failed to be administered the Ciprofloxin on 09/04/23 at 6:00 A.M. The resident was to receive six doses total.
Interview on 09/07/23 at 11:42 A.M., with the Director of Nursing (DON) stated the Voltaren was sometimes held for Resident #17 if she was sleeping, but the reason for the missed times failed to be documented. The DON also verified the Ciprofloxin was not administered timely and there was no documentation as to the reason.
Review of the policy titled Medication Administration, with review date of 05/29/19, revealed medications would be administered within the time frame of one hour before and up to one hour after time ordered. Medications that are refused or withheld or not given will be documented.
This was an incidental finding discovered during the complaint investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to ensure residents received assistive devices with meals. This affected one (#11) of three residents reviewed for assistive devices. The facility census was 78.
Findings include:
Review of the medical record for Resident #11 revealed an admission date of 05/31/13 with diagnoses of depression, insomnia, and paranoid schizophrenia.
Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #11 had impaired cognition and required limited assistance of one person for eating.
Review of a physician order dated 04/06/23 revealed Resident #11 required a spouted cup with meals.
Review of Resident #11's current care plan updated 07/29/23 revealed he had a nutritional problem due to receiving a mechanically altered diet. Interventions included a divided plate and spouted cup at every meal.
Review of the meal ticket for Resident #11 for the noon meal on 09/05/23 revealed he should receive a spouted cup and divided plate with meals.
Observation and interview on 09/05/23 at 12:45 P.M., with Licensed Practical Nurse (LPN) #269 confirmed Resident #11 received his meal on a regular plate and did not receive a divided plate as was specified on his meal ticket.
This deficiency represents non-compliance investigated under Complaint Number OH00145743.

Based on observations, staff interviews, review of facility identified diet list, review of the facility temperature logs, and review of the facility policies, the facility failed to ensure refrigerator and freezer temperatures were monitored daily. This had the potential to affect all residents in the facility except 10 residents (#38, #57, #58, #59, #61, #62, #68, #69, #86, and #102) identified to receive no food from the kitchen. Additionally, the facility failed to ensure staff followed proper hand hygiene when serving meals to residents in the dining room. This affected 13 residents (#11, #13, #14, #17, #22, #23, #25, #27, #30, #31, #46, #51, and #53) in the dining room who received cheese ravioli. The facility census was 78.
Findings include:
1. Observation on 09/05/23 at 10:05 A.M., revealed the August 2023 temperature logs were incomplete from 08/24/23 through 08/31/23 for the milk refrigerator, the reach-in refrigerator, and walk-in refrigerator and the walk-in freezer.
Interview on 09/05/23 at 10:05 A.M., with the Dietary Manager #286 confirmed the temperature logs were incomplete.
Review of the policy Food Storage: Cold Foods, revised March 2018, revealed a written record of daily temperatures will be recorded.
2. Observations beginning on 09/06/23 at 12:15 P.M., revealed Director of Social Services (DSS) #200 plating food for the noon meal. DSS #200 was wearing plastic gloves when she picked up a plate, a meal ticket, touched the utensil to stir sauce, then picked up three cheese ravioli by hand, placed them on the plate, used the utensil to scoop and pour sauce over the ravioli, picked up a slice of garlic bread with her gloved hand and placed it on the plate, then picked up a pre-portioned salad and placed the plate and salad on top of the serving line for the dietary aide to retrieve and place on the resident's tray. Continued observation revealed DSS #200 did not wash her hands or change her gloves and proceeded to plate resident meals while touching non-food items, including serving utensils, meal tickets, and pre-portioned salad while also picking up each cheese ravioli and garlic bread with her gloved hands for residents in the dining room.
Interview on 09/06/23 at 12:25 P.M., with DSS #200 confirmed she touched ready-to-eat foods with the same gloves as she touched several other non-food items. DSS #200 stated she used her gloves to pick up the ravioli because she did not want to damage the shell by using a utensil.
Further observation revealed no attempt to re-serve the dining room residents who received plates with cheese ravioli.
Interview on 09/06/23 at approximately 4:00 P.M., with District Manager for Dietary Services #289, confirmed DSS #200 practiced unsafe food handling by touching non-food items between touching ready-to-eat items without washing her hands and changing her gloves.
Review of facility identified diet list revealed 10 residents (#38, #57, #58, #59, #61, #62, #68, #69, #86, and #102) who do not receive meals from the kitchen. The facility identified 13 residents (#11, #13, #14, #17, #22, #23, #25, #27, #30, #31, #46, #51, and #53) in the dining room who received cheese ravioli.
This deficiency represents non-compliance investigated under Complaint Number OH00145743.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure staff accurately documented completed tasks in the medical record. This affected one (#30) of 14 records reviewed. The facility census was 78.
Findings include:
Review of Resident #30's medical record revealed an admission date of 06/27/17, with a diagnosis of dementia.
Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had impaired cognition.
Review of a physician order dated 11/17/22 revealed Resident #30 required staff to check the function of his wandering device on day and night shifts.
Review of the Treatment Administration Record (TAR) for the evening shift on 09/02/23 revealed Licensed Practical Nurse (LPN) #252 checked the function on Resident #30's wandering device.
Interview on 09/05/23 at 9:28 A.M., with LPN #252 revealed she had residents on her hall with a wandering device but could not identify them at that time.
Follow-up interview and observation on 09/05/23 at 2:31 P.M., with LPN #252 revealed she checked the placement of Resident #30's wandering device on his left ankle. Further interview at that time with LPN #252 revealed she performed no additional tasks other than verifying placement when monitoring residents with a wandering device. LPN #252 revealed the functioning of the device was checked by maintenance or the on-call manager. LPN #252 confirmed she documented on Resident #30's TAR on 09/02/23 that she checked the functioning of his wandering device. LPN #252 stated the maintenance person and the on-call manager do not have access to the orders, she had to complete for Resident #30, so she documented the task was completed.
Interview on 09/05/23 at approximately 3:25 P.M., with Unit Manager (UM) #201 informed the surveyor, LPN #252 was knowledgeable about when and how to check the functionality of wandering devices on residents' ankles at bedside and LPN #252 misunderstood the surveyor's question. UM #201 further stated maintenance, or the on-call manager checked the functioning of the doors in response to the wandering device, but nurses were responsible for checking the functionality of the wandering device on each resident's ankle.
Interview on 09/05/23 at approximately 3:27 P.M., with LPN #252 revealed the functionality of the wandering device on each resident's ankle was checked by the maintenance.
This deficiency represents non-compliance investigated under Complaint Number OH00145743.

Based on observation, medical record review, staff interview, and policy review, revealed facility staff failed to follow the infection control protocol when caring for residents. This affected one (#86) of one residents observed in isolation. The facility census was 78.
Findings included:
Review of Resident #86's medical record revealed an admission date of 09/06/23, with diagnoses including: colon cancer, liver cancer, prostate cancer, and lung cancer. The resident had a history of multi-drug resistant organism (MDRO).
Review of Resident #86's medical record revealed a physician's order dated 09/05/23 for enhanced barrier precautions related to a history of MDRO when dressing, bathing, showering, transferring, personal hygiene, changing linens, toileting, and peri care. Providing care to resident with a history of colonized multi-drug resistant organism; klebsiella pneumoniae.
Observation on 09/06/23 at 3:41 P.M., Resident #86's room door was closed with a sign posted which revealed the resident was on enhanced barrier precautions and any staff coming in contact with the resident was required to wear personal protective equipment (PPE). Hanging on the door was a receptacle which contained gowns, gloves, and masks. On entering the room Physical Therapist #256 was observed providing therapy to Resident #86. The therapist was viewed raising and lowering the residents legs up and down off of his bed without the benefit of personal protective equipment including gloves.
Interview on 09/06/23 at 3:45 P.M., with Physical Therapist #256 and Infection Control Preventionist #217 verified the therapist failed to wear proper PPE as required.
Review of the policy titled PPE General Statement, with review date of 02/25/22, revealed employees are required to use PPE when indicated to reduce exposure risks.
This incidental finding was found during the complaint survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain a peripherally inserted central catheter (PICC) line per physician orders. This affected one (#65) of one residents reviewed for peripheral vascular access. The facility identified five residents with peripheral vascular access lines. The facility census was 72.
Findings include:
Review of Resident #65's medical record revealed an admission date of 06/09/23. Diagnoses included gastrointestinal stromal tumor of the large intestine, pneumonia, chronic obstructive pulmonary disease (COPD), type II diabetes, emphysema, neoplasm of unspecified behavior of the digestive system, hypertension, depression, anxiety disorder, and malignant neoplasm of lower lobe, right bronchus, or lung.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 was cognitively intact, received antibiotics, and received intravenous (IV) medications.
Review of the plan of care, initiated 06/12/23, revealed Resident #65 had an IV access. Interventions included to administer medications per medical provider orders, enhanced barrier precautions, monitor vital signs, and visually inspect the IV site each shift. In addition, Resident #65 had pneumonia of the right lower lobe. Interventions included to administer medications per medical provider's orders, enhanced barrier precautions, and oxygen as ordered.
Review of a physician order dated 06/09/23, and discontinued on 06/13/23, revealed cefazolin sodium (antibiotic) injection solution reconstituted two grams (gm), use 2000 milligrams (mg) intravenously three times a day for infection until 06/23/23. Additional review revealed a physician order dated 06/09/23, and discontinued on 06/23/23, for heparin sodium (used to prevent blood clots in a PICC line) lock flush intravenous solution 10 unit/milliliter (ml) use five ml intravenously three times a day for cefazolin usage until 02/23/23. Review of a physician order dated 06/09/23 revealed Resident #65 was to receive normal saline flush IV solution 0.9 percent (%) 10 ml IV three times a day for cefazolin usage until 06/23/23 with instruction to flush ports/lumes before and after IV administration. Review of a physician order dated 06/10/23, and end date 06/11/23, revealed Cathflo Activase (used to restore function of PICC line - also referred to by staff as clot buster) injection solution reconstituted two mg use one dose intravenously one time only for health maintenance. Lastly, review of a physician order dated 06/11/23, and end date of 06/12/23, revealed Cathflo Activase injection solution reconstituted use two mg intravenously one time only for infection/occluded PICC line for one day, please send two vials.
Review of the Medication Administration Record (MAR) from 06/09/23 through 06/30/23 revealed cefazolin sodium was documented as 9, with 9 indicating to see nurses notes, the night dose on 06/09/23. Review of the corresponding nurses note dated 06/10/23 at 12:21 A.M. revealed the medication was on order. Further review revealed on 06/10/23, both the morning and afternoon doses were administered as ordered. The night dose on 06/10/23 was documented as 5, indicating the medication was on hold. Review of the corresponding nurses note dated 06/10/23 at 8:48 P.M. revealed the medication was held pending declot of PICC. The morning and afternoon doses on 06/11/23 were also documented as 5. Review of a nurses note dated 06/11/23 at 10:34 A.M. revealed morning dose of cefazolin held due to waiting for Cathflo to arrive and a nurses note dated 06/11/23 at 1:49 P.M. revealed not able to give medication. Beginning with the night dose on 06/11/23, the medication was placed on hold. A total of six consecutive doses of cefazolin sodium was not administered between the night shift dose on 06/10/23 and the afternoon shift on 06/12/23.
Additional review of the MAR revealed heparin sodium was documented as 9 for the night dose on 06/09/23. Review of the corresponding nurses note dated 06/10/23 at 12:23 A.M. revealed the medication was on order. The morning dose on 06/10/23 was documented as 9 and the corresponding nurses note dated 06/10/23 at 7:33 A.M. revealed no information on why the medication was not administered. The 06/10/23 afternoon dose was also documented as 9, with the corresponding nurses note dated 06/10/23 at 12:44 P.M. not indicating why the medication was not administered. On 06/10/23, the night dose was documented as 9 with no corresponding nurses note. On 06/11/23, the morning and afternoon doses were documented as 5. Review of a nurses note dated 06/11/23 at 10:07 A.M. revealed unable to give and on 06/11/23 at 1:41 P.M. revealed the medication was not administered due to a clotted PICC. On 06/12/23, both the morning and afternoon doses of heparin were documented as 9. Review of a nurses note dated 06/12/23 at 1:33 P.M. revealed the medication was not administered and waiting on clot buster. Further review of the MAR revealed the night dose on 06/12/23 and the morning dose on 06/13/23 were administered and heparin was then discontinued.
Further review of the MAR revealed Cathflo Activase, ordered on 06/10/23, had no administration documented on 06/10/23. On 06/11/23, the medication administration was documented as 9. Review of a corresponding nurses note, dated 06/11/23 at 1:48 P.M. revealed Registered Nurse (RN) on site attempted to give with no access. Made call to access RN. On 06/11/23, the MAR indicated no documentation for the Cathflo Activase (second order) administration. On 06/12/23, the medication was administered and a corresponding nurses note dated 06/12/23 at 8:30 P.M. revealed Cathflo administration successful and lumens flushed.
Additional review of nursing progress notes from 06/10/23, when Resident #65's PICC line was initially noted to be clotted, through 06/12/23, when PICC line access was reestablished, revealed no additional information related to interventions to reestablish PICC line access.
Interview on 07/13/23 at 9:19 A.M. of the Director of Nursing (DON) confirmed Resident #65 had a PICC line upon admission for the administration of IV antibiotics related to pneumonia. The DON stated, while Resident #65 had a physician order for heparin sodium flushes, the order was a general order generated with PICC line usage, but based on standard of practice, would not have been appropriate to use. The DON stated the pharmacy would not have even filled the order because it was not clinically indicated. The DON verified heparin sodium had not been used to flush Resident #65's PICC line, as indicated per physician order, and the resident subsequently had a clotted PICC line. In addition, the DON confirmed the clotted PICC line was first discovered on 06/10/23. While an attempt was made on 06/11/23 to regain access to the PICC line, there was no other documentation the facility implemented any interventions to reestablish access to the line until approximately 8:30 P.M. on 06/12/23. As a result, Resident #65's antibiotic treatment was delayed, for a total of nine missed doses, and an extension of IV antibiotic treatment.
Interview on 07/13/23 at 11:02 A.M. of Quality Assurance Pharmacist (QAP) #400 revealed the facility had submitted the heparin sodium order as a profile order, meaning the facility did not want the medication sent but to be on file as an ordered medication. QAP #400 verified the pharmacy did not fill the order, however, the facility pulled a vial of the medication from their contingency supply for Resident #65 on 06/10/23. QAP #400 denied the pharmacy would not have filled a physician order because they determined a medication was not clinically appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure timely incontinence care was provided. This affected one (#14) of one residents reviewed for the provision of incontinence care. The facility census was 72.
Findings include:
Review of the medical record revealed Resident #14 admitted to the facility on [DATE] with the diagnoses including cerebral infarction affecting the right dominant side, Alzheimer's disease, dementia, hypertension, atrial fibrillation, type II diabetes mellitus, anemia, and contracture of the left and right ankle.
Review of the Minimum Data Set assessment dated [DATE] revealed Resident #14 was assessed with severe cognitive impairment, required two plus staff members for bed mobility and transfers, was dependent on staff for the completion of activities of daily living including toilet use and personal hygiene, and was incontinent of bowel and bladder.
Review of Resident #14's medical record noted a nursing plan of care revised on 10/18/22 which addressed urinary incontinence due to impaired cognition and impaired mobility. Interventions included to check the resident for incontinence, wash, rinse and dry perineum, and change clothing as needed after incontinence episodes. On 05/25/23, an additional plan of care was initiated addressing Resident #14 bowel incontinence. Interventions included to provide assistance with toileting as needed and provide peri-care after each incontinence episode.
Further review of Resident #14's medical record lacked documentation indicating a frequency regarding incontinence checks or toileting opportunities.
Observation on 07/11/23 at 10:08 A.M. noted Resident #14 seated in a geriatric chair (a large, padded chair to help individuals with limited mobility) in the facility dining room. At 12:05 P.M., the resident remained seated in the geriatric chair in the dining room. At 1:20 P.M., the resident was transported into the unit lounge and remained seated in the geriatric chair.
On 07/11/23 at 1:23 P.M., interview with State Tested Nurse Aide (STNA) #390 verified assuming care of Resident #14 at 10:30 A.M. STNA #390 confirmed she was not aware when the resident was last check or changed for incontinence since assuming care. STNA #390 indicated the resident was already dressed and seated in the geriatric chair when she assumed the resident's care.
On 07/11/23 at 1:37 P.M., Resident #14 was placed to bed using a mechanical lift by STNA #390, STNA #364, and STNA #381. STNA #390 removed Resident #14 pants and discovered the resident with two adult briefs applied and a feminine pad contained inside the briefs. The resident was incontinent of a moderate amount of bowel in the perineal area (anterior peri-area).
On 07/11/23 at 1:50 P.M., interview with Licensed Practical Nurse (LPN) #331 verified Resident #14 was to be checked and changed every two hours for incontinence. LPN #331 was not aware the resident was not checked for incontinence or repositioning since approximately 10:30 A.M.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to provide timely repositioning regarding dependent resident assessed at risk for pressure ulcer development. This affected one (#14) two residents reviewed for repositioning and pressure-reducing interventions. The facility census was 72.
Findings include:
Review of Resident #14's medical record revealed admission to the facility on [DATE] with the diagnoses including cerebral infarction affecting right dominant side, Alzheimer's disease, dementia, hypertension, atrial fibrillation, type II diabetes mellitus, anemia, contracture left and right ankle.
Review of the Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #14 with severe cognitive impairment, the resident was assessed to require two plus staff members for bed mobility and transfers, was dependent on staff for the completion of activities of daily living including toilet use and personal hygiene, and was assessed at risk for pressure ulcer development.
Review of Resident #14's medical record revealed a nursing plan of care revised 11/28/22 addressing Resident #14 activity of daily living self care performance deficit. Interventions included the resident was non-ambulatory and required a two person assist with bed mobility, staff will utilize a geriatric chair (a large padded chair designed to assist individuals with limited mobility) due to hemiplegia and leaning to the side, the resident requires use of mechanical lift (Hoyer) with a two person support with transfer. On 10/18/22 a nursing plan of care was developed to address risk for altered skin integrity due to weakness, difficulty ambulating, incontinence, cognitive deficits, type II diabetes mellitus and interventions included to ensure residents are turned and repositioned as tolerated.
Further review of Resident #14's medical record lacked documentation indicating a frequency regarding repositioning.
Observation on 07/11/23 at 10:08 A.M., noted Resident #14 seated in a geriatric chair (geri-chair) in the facility dining room. At 12:05 P.M., the resident remained seated in the geri-chair in the dining room. At 1:20 P.M., the resident was transported into the unit lounge seated in the geri-chair.
On 07/11/23 at 1:23 P.M., interview with State Tested Nurse Aide (STNA) #390 stated she assumed care of Resident #14 at 10:30 A.M. STNA #390 confirmed she was not aware when the resident was last repositioned since assuming care. STNA #390 indicated the resident was already dressed and seated in the geri-chair when she assumed the resident's care.
On 07/11/23 at 1:37 P.M., Resident #14 was placed to bed using a mechanical lift by STNA #390, STNA #364, and STNA #381. STNA #390 removed Resident #14 pants to check for incontinence and Resident #14 was observed to have no skin breakdown.
On 07/11/23 at 1:50 P.M., interview with Licensed Practical Nurse (LPN) #331 verified Resident #14 was to be repositioned every two hours for pressure ulcer prevention. LPN #331 was not aware the resident was not repositioned since approximately 10:30 A.M. on 07/11/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident interview, resident representative interview, staff interview, and review of a facility policy, the facility failed to ensure dependent residents received assistance with bathing, personal hygiene, and transfers. This affected three (#62, #14, and #60) of five residents reviewed for activities of daily living. The facility census was 72.
Findings include:
1. Review of Resident #62's medical record revealed an admission date of 02/28/23. Diagnoses included chronic obstructive pulmonary disease (COPD), type II diabetes, hypertension, cerebral infarction, difficulty walking, morbid obesity, and polyneuropathy.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was cognitively intact and required extensive assistance with dressing, toilet use, and personal hygiene. Additionally, Resident #62 had no refusals of care.
Review of the plan of care initiated 02/28/23 revealed Resident #62 had an activities of daily living (ADL) self-care performance deficit and required assistance with ADLs with an intervention for staff assistance required.
Review of state tested nurse aide (STNA) documentation from 06/15/23 through 07/12/23 revealed Resident #62 received showers on 06/15/23, 06/29/23, and 07/03/23 and a bed bath on 06/19/23. Further review revealed STNAs documented not applicable on 06/26/23, 07/06/23, and 07/10/23.
Review of nursing progress notes from 06/15/23 through 07/12/23 revealed no documentation Resident #62 refused care.
Observation on 07/11/23 at 1:32 P.M. of Resident #62 revealed the resident's hair appeared greasy.
Interview with Resident #62 at the time of the observation revealed he was uncertain when he last received a shower. Resident #62 stated he was supposed to get a shower on 07/11/23, but had not received it yet and did not always get them when he was supposed to. Resident #62 denied refusing care, and stated it bothered him when his showers were not provided, but he did not complain because it did not do any good to complain.
Additional observations on 07/11/23 at 2:42 P.M. and on 07/12/23 at 7:14 A.M., at 9:11 A.M., and at 11:06 A.M. revealed Resident #62's hair continued to appear unwashed and greasy.
Interview on 07/12/23 at 9:29 A.M. with STNA #363 stated, to her knowledge, Resident #62 was cooperative and did not typically refuse care. STNA #363 confirmed Resident #62's hair appeared unwashed. STNA #363 stated she did not have information about Resident #62's showers.
Interview on 07/12/23 at 9:38 A.M. with the Director of Nursing (DON) revealed Resident #62 was usually cooperative with care, but personal hygiene was not always a priority for him. The DON confirmed Resident #62's shower days were Tuesdays and Fridays, and the resident should have received a shower on 07/11/23. The DON verified there was no documentation Resident #62 received a shower on 07/11/23 and the medical record did not indicate refusal of care. The DON confirmed the last shower documented for Resident #62 was on 07/03/23 and she was unsure why the resident did not receive a shower on 07/11/23.
Follow-up interview on 07/12/23 at 11:06 A.M., with Resident #62 revealed he still had not received a shower. Resident #62 stated he did not refuse showers and would like to have them when scheduled.
Review of facility policy titled, Routine Resident Care, revealed routine care by a nursing assistant included, but is not limited to, assisting or providing for personal care with bathing, dressing, eating and hydration, and toileting.
2. Review of Resident #14's medical record revealed admission to the facility on [DATE] with diagnoses including, cerebral infarction affecting the right dominant side, Alzheimer's disease, dementia, hypertension, atrial fibrillation, type II diabetes mellitus, anemia, and contracture of the left and right ankle.
Review of the MDS assessment dated [DATE] revealed Resident #14 was assessed with severe cognitive impairment, required two plus staff members for bed mobility and transfers, was dependent on staff for the completion of activities of daily living including toilet use and personal hygiene, and was incontinent of bowel and bladder.
Review of a nursing plan of care dated 11/28/22 revealed it was was revised to address Resident #14's activity of daily living self care performance deficit with interventions including the resident required one person assistance with hygiene, bathing, and toileting.
Observation on 07/10/23 at 11:59 A.M., discovered Resident #14 with jagged, long fingernails with brownish-black debris under the nails. At 12:12 P.M., the resident was observed in the dining room feeding herself at times with her hands and the fingernails remained jagged with brownish-black substance underneath. On 07/11/23, at 9:04 A.M. and 3:39 P.M., the resident was again observed with jagged fingernails with a brownish-black substance under the fingernails.
On 07/11/23 at 1:23 P.M., interview with STNA #390 confirmed Resident #14 fingernails were soiled with jagged edges.
3. Review of Resident #60's medical record revealed admission to the facility on [DATE]. Diagnoses including, acute and chronic respiratory failure, idiopathic epilepsy, tracheostomy, gastrostomy, cerebral aneurysm, aortic aneurysm, anxiety disorder, hypertension, contracture upper arm, right and left knee, muscle wasting and atrophy, and pressure ulcers to left ankle and sacral region.
Review of the Minimum Data Set assessment dated [DATE] revealed Resident #60 was assessed with severely impaired cognition, was unable to make needs known, required total dependence on staff for completion of activities of daily living including bed mobility and transfers, utilized an indwelling urinary catheter, was incontinent of bowel, and received all nutrition via feeding tube.
Review of Resident #60's medical record revealed on 05/04/23 a nursing plan of care was developed to address Resident #60's activity of daily living (ADL) self care performance deficit, indicating Resident #60 required assistance with ADL functional deficits due to weakness, seizure disorder, cerebral aneurysm, and status post craniotomy (a surgical opening of the skull). Interventions included to provide assistive devices as needed, the resident required one to two staff member assistance with bed mobility, and the resident required two staff member assistance with transfers using a mechanical lift.
Review of a wound specialist assessment report dated 05/05/23 noted a right superior orbital deep tissue injury (persistent non-blanchable deep red, maroon, or purple discoloration) measuring 0.80 centimeter (cm) long by 2.40 cm wide was evaluated. and a treatment included cleansing, applying skin prep, leave open to air, to bed administered twice daily was ordered. Further review of the medical record lacked documentation indicating the cause of the deep tissue injury or instructions to hold the application of a helmet while out of bed. On 05/17/23, the wound specialist assessed the wound as healed.
Review of the medical record revealed on 06/08/23, Resident #60 was evaluated by a neurologist and there was no documentation which indicated the helmet was held due to causing skin breakdown or alternative interventions utilized to promote Resident #60 ability to be out of bed.
Further review of Resident #60's medical record lacked documentation indicating the resident was transferred out of bed for out of bed activities.
On 07/10/23 at 12:25 P.M., interview with Resident #60's responsible party stated Resident #60 had not been out of bed since admission to the facility.
Observation on 07/10/23 at 9:59 A.M., 10:30 A.M. 1:10 P.M., 3:15 P.M., 4:39 P.M., on 07/11/23 at 6:30 A.M., 10:30 A.M., 12:07 P.M., and on 07/12/23 at 6:21 A.M., 9:39 A.M., and 10:30 A.M. revealed Resident #60 was observed in bed dressed in a hospital house gown.
On 07/11/23 at 1:57 P.M., interview with STNA #316 confirmed Resident #60 did not get out of bed and had been out of bed since admission.
On 07/11/23 at 2:03 P.M., interview with the Director of Nursing (DON) confirmed Resident #60 had not been out of bed due to a new helmet was on order and the material not available. The DON stated there was no information available indicating when a helmet would be obtained or any alternative interventions utilized to assist in giving Resident #60 opportunities to get out of bed.

Based on observation, resident and staff interview, the facility failed to ensure resident equipment was maintained in a clean and sanitary manner. This affected two (#40 and #58) of five residents reviewed for a clean and sanitary environment. The facility census was 72.
Findings include:
1. Observation on 07/10/23 at 10:10 A.M., revealed Resident #40's electric wheelchair leg rest and foot area was covered with a thick layer of dirt and debris. An unknown brown thick substance was dripped on the leg area approximately three to five inches. Interview with Resident #40 during the observation voiced his wheelchair had never been cleaned.
Interview on 07/10/23 at 5:05 P.M., with State Tested Nurse Aide (STNA) #381 verified Resident #40's wheelchair was very dirty and needed cleaned. STNA #381 stated third shift staff clean resident wheelchairs.
Observation on 07/11/23 at 11:11 A.M., revealed Resident #40's wheelchair continued to remain dirty and in need of cleaning.
Observation on 07/12/23 at 10:08 A.M., revealed Resident #40's wheelchair continued to remain dirty and in need of cleaning.
Observation on 07/13/23 at 1:29 P.M., revealed Resident #40's wheelchair continued to remain dirty and in need of cleaning.
2. Observation on 07/10/23 at 10:20 A.M., revealed the legs of Resident #58's tube feeding pole had a thick layer of dust and dirt in addition to what appeared to be tube feeding solution splatter.
Observation on 07/11/23 at 11:09 A.M., revealed the legs of Resident #58's tube feeding pole continued to be dirty and in need of cleaning.
Observation on 07/12/23 at 9:53 A.M., revealed the legs of Resident #58's tube feeding pole continued to be dirty and in need of cleaning.
Interview on 07/12/23 at 9:54 A.M., with STNA #364 verified the legs of Resident #58's tube feeding pole were dirty and in need of cleaning.

Based on observation, resident and staff interview, and facility policy review, the facility failed to ensure food was stored and served in a safe and sanitary manner. This had the potential to affect all residents except eight (#13, #18, #25, #49, #57, #58, #60, and #61) residents the facility identified who did not receive food from the kitchen. The facility census was 72.
Findings include:
1. Observation on 07/10/23 at 9:05 A.M. of the kitchen revealed a disposable cup in the sugar bin on top of the sugar. Observation of the stand-up refrigerator revealed a reusable container of what appeared to be chicken noodle soup approximately one-fifth full with no date or label. Observation of the walk-in refrigerator revealed a food delivery box on top which was sitting inside of another box. Upon lifting the top box up, it was discovered the bottom box had leaf lettuce inside with no barrier and the leaf lettuce was in contact with the bottom of the food delivery box that was sitting inside it.
Interview on 07/10/23 at 9:10 A.M., with Dietary Manager #367 verified the cup inside the sugar bin and the unlabeled and undated chicken noodle soup.
Interview on 07/10/23 at 9:16 A.M., with [NAME] #388 verified the delivery box bottom was placed directly on top of the uncovered leaf lettuce.
2. Review of Resident #122's medical record revealed an admission date of 07/02/23. Diagnoses included obstructive hypertrophic cardiomyopathy, bradycardia, hemiplegia and hemiparesis, chronic kidney disease, malignant neoplasm of sigmoid colon, cerebral infarction, atherosclerotic heart disease, and dysphagia.
Observation on 07/11/23 at 1:33 P.M. of Resident #122's room revealed the resident was out of the facility for a medical appointment. Resident #122's lunch tray was sitting on the over the bed table. Additional observation on 07/11/23 at 3:30 P.M., revealed Resident #122 had not return to the facility from his medical appointment and the lunch meal tray remained on the resident's over the bed table.
Observation on 07/11/23 at 4:25 P.M. revealed Resident #122 had returned from his appointment. Resident #122 was laying in bed. The over the bed table was in front of the resident and Resident #122 had eaten several bites of the lunch meal, which included pork, sweet potatoes, and fruit.
Interview with Resident #122 at the time of the observation on 07/11/23 at 4:25 P.M. confirmed the meal tray was in his room when he returned from his appointment and the staff had given him the meal to eat. Resident #122 denied staff had reheated the meal prior to giving it to him.
Interview on 07/11/23 at 4:35 P.M. with State Tested Nurse Aide (STNA) #374 confirmed she provided Resident #122 with his lunch meal tray upon his return to the facility from a medical appointment. STNA #374 verified the lunch meal tray had been sitting in Resident #122's room for several hours and had neither been refrigerated or reheated prior to her providing the meal to the resident.
Review of facility policy titled, Food: Preparation, revised September 2017, revealed all foods will be held at appropriate temperatures, greater than 135 degrees Fahrenheit (F) for hot food holding, and less than 41 degrees F for cold food holding. Additionally, if food is not reheated within two hours, it must be discarded.
3. Observation on 07/10/23 at 12:30 P.M., revealed Resident #26 received the lunch meal tray. Continued observation revealed a meal tray with partially eaten food in the resident's room near the bed. Interview with Resident #26 at the time of the observation revealed it was last night's dinner.
Review of the meal tray ticket dated 07/09/23 revealed the food provided included garlic herb pork loin, garlic roasted red skin potatoes, seasoned cabbage, dinner roll, and baked apples.
Interview on 07/10/23 at 12:33 P.M., with Human Resource Manager #387 verified a meal tray from the dinner meal from 07/09/23 was left in Resident #26's room until lunch 07/10/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, staff interview, and review of an owner's manual for an air mattress, the facility failed to ensure medical equipment was utilized in a safe manner. This affected one (#4) of four residents reviewed for accidents and hazards. The facility census was 72.
Findings include:
Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, dependence on respirator, tracheostomy, chronic obstructive pulmonary disease, hypertension, polyneuropathy, low back pain, type II diabetes mellitus, peripheral vascular disease, left knee contracture, anxiety disorder, and major depression.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was assessed with intact cognition, required extensive assistance of one staff for bed mobility, and required physical assistance of one person for locomotion using a wheelchair with no history of sustaining falls.
Review of a fall risk assessment dated [DATE] revealed Resident #4 was at risk of falling.
Review of a nursing plan of care dated 03/09/23 revealed it was revised to address Resident #4's risk of falling related to gait and balance problems, diagnoses of respiratory failure with tracheostomy, ventilator, and oxygen use, obesity, back pain, weakness, shortness of breath with fatigue, medications, and non-compliance with repositioning to the right side. It was noted the resident only laid on left side at edge of bed. Interventions included to educate the resident not to lay on the side of bed, provide a safe environment with even floors free from spills and/or clutter, provide adequate and glare-free light, provide a working and reachable call light, maintain the bed in low position at night, provide handrails on walls, keep personal items within reach, and reposition the mattress.
Review of the medical record revealed on 05/04/23 a physician order was initiated for a low air loss mattress to be applied to Resident #4's bed for for pressure and moisture reduction.
Review of treatment administration records between 05/04/23 and 07/10/23 noted the low air loss mattress for pressure and moisture reduction was documented as in place twice daily (documented during the day and at night). There were no settings for the air mattress listed or contained in the medical record.
Review of the owner's manual for the mattress applied to Resident #4's bed, dated November 2017, revealed warning information included the product may not be suitable for all individuals and other devices may be required. The resident's body cannot exceed the width of the mattress at any weight capacity. The user should increase firmness if necessary for resident comfort, support, and immersion into the mattress.
Observation on 07/10/23 at 10:30 A.M., discovered Resident #4 in bed with a bariatric air mattress hanging over the side of the bed frame. Interview with the resident at the time of observation voiced feeling unsafe in the bed with fear of falling.
On 07/11/23 at 8:56 A.M. and 10:15 A.M., Resident #4 was observed in bed with the left side of the air mattress hanging over the left side of the bed frame.
On 07/11/23 at 10:18 A.M., interview with Licensed Practical Nurse (LPN) #354 verified Resident #4's air mattress was not fitting the bed frame. LPN #354 was not aware of the air mattress setting or how to check for appropriate use or application. Interview with Resident #4 at that time again voiced concerns with falling from the bed.
On 07/11/23 at 12:59 P.M., interview with Director of Plant Maintenance (DPM) #335 stated the mattress was 48 inches wide, a bariatric style, and the frame was fully extended to support the mattress. DPM #335 confirmed the mattress extended over side of Resident #4's bed frame due to the resident laying on the left side. DPM #335 stated the mattress was placed to the bed by maintenance staff and the settings and monitoring of the mattress are maintained by nursing.
On 07/12/23 at 6:30 A.M., observation with Registered Nurse (RN) #302 confirmed Resident #4's air mattress extended over the side of the bed frame and was not contained within bed frame parameters.
On 07/13/23 at 8:58 A.M., interview with the Director of Nursing confirmed treatment administration records and physician orders do not indicate specific air mattress settings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure medications were not left at the bedside. This affected two (#59 and #70) of four residents observed for medication storage. The facility census was 72.
Findings include:
1. Review of Resident #59's medical record revealed an admission date of 02/16/23. Diagnosis included a stage four pressure ulcer to bilateral hips, chronic obstructive pulmonary disease, chronic kidney disease, congestive heart failure, and contractures of the bilateral ankles.
Observation on 07/10/23 at 10:31 A.M. revealed Resident #59 had a medication cup on her bedside table which contained her morning medication.
Interview with Resident #59 on 07/10/23 at 10:31 A.M. stated the nurse left the medication cup on the table for her to take at her leisure.
Interview with Licensed Practical Nurse (LPN) #356 on 07/10/23 at 10:33 A.M. verified the morning nurse left the medication unattended in Resident #59's room.
2. Review of Resident #70's medical record revealed the resident was admitted to the facility on [DATE] and discharged on 05/01/23. Diagnoses included chronic obstructive pulmonary disease, sepsis due to methicillin susceptible staphylococcus aureus, end stage renal disease, type two diabetes mellitus with hyperglycemia, portal hypertension, unspecified cirrhosis of liver, acute respiratory failure with hypoxia, dyspnea, chronic kidney disease stage three, unspecified osteoarthritis, and hypothyroidism.
Review of a nursing progress note dated 05/01/23 at 12:00 A.M. revealed earlier in the shift at 9:00 P.M. the nurse entered Resident #70's room for as needed pain medication and to obtain vital signs. The nurse noted Resident #70 had not taken medications from the previous nurse as the medications were still on the tray table . The nurse informed the resident the medications would be retrieved because the medications were not taken timely. The medications included the heartburn medication Prilosec 20 milligrams (mg) and the blood pressure medication Midodrine 10 mg.
Interview on 07/11/23 at 3:40 P.M., with the Director of Nursing (DON) verified the nursing progress note documented Resident #70's medication was left at the bedside.
Review of the facility policy titled, Medication Administration, revised 12/14/17, revealed nurses were to never leave medications unattended. They were to remain with resident until the medication was swallowed and not leave leave mediations at bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain a peripherally inserted central catheter (PICC) line which resulted in the delay of administering an intravenous (IV) antibiotic medication as ordered. This affected one (#65) of five residents reviewed for medications. The facility census was 72.
Findings include:
Review of Resident #65's medical record revealed an admission date of 06/09/23. Diagnoses included gastrointestinal stromal tumor of the large intestine, pneumonia, chronic obstructive pulmonary disease (COPD), type II diabetes, emphysema, neoplasm of unspecified behavior of the digestive system, hypertension, depression, anxiety disorder, and malignant neoplasm of lower lobe, right bronchus, or lung.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 was cognitively intact, received antibiotics, and received intravenous (IV) medications.
Review of the plan of care, initiated 06/12/23, revealed Resident #65 had an IV access. Interventions included to administer medications per medical provider orders, enhanced barrier precautions, monitor vital signs, and visually inspect the IV site each shift. In addition, Resident #65 had pneumonia of the right lower lobe. Interventions included to administer medications per medical provider's orders, enhanced barrier precautions, and oxygen as ordered.
Review of a physician order dated 06/09/23, and discontinued on 06/13/23, revealed cefazolin sodium (antibiotic) injection solution reconstituted two grams (gm), use 2000 milligrams (mg) intravenously three times a day for infection until 06/23/23. Additional review revealed a physician order dated 06/09/23, and discontinued on 06/23/23, for heparin sodium (used to prevent blood clots in a PICC line) lock flush intravenous solution 10 unit/milliliter (ml) use five ml intravenously three times a day for cefazolin usage until 02/23/23. Review of a physician order dated 06/09/23 revealed Resident #65 was to receive normal saline flush IV solution 0.9 percent (%) 10 ml IV three times a day for cefazolin usage until 06/23/23 with instruction to flush ports/lumes before and after IV administration. Review of a physician order dated 06/10/23, and end date 06/11/23, revealed Cathflo Activase (used to restore function of PICC line - also referred to by staff as clot buster) injection solution reconstituted two mg use one dose intravenously one time only for health maintenance. Lastly, review of a physician order dated 06/11/23, and end date of 06/12/23, revealed Cathflo Activase injection solution reconstituted use two mg intravenously one time only for infection/occluded PICC line for one day, please send two vials.
Review of the Medication Administration Record (MAR) from 06/09/23 through 06/30/23 revealed cefazolin sodium was documented as 9, with 9 indicating to see nurses notes, the night dose on 06/09/23. Review of the corresponding nurses note dated 06/10/23 at 12:21 A.M. revealed the medication was on order. Further review revealed on 06/10/23, both the morning and afternoon doses were administered as ordered. The night dose on 06/10/23 was documented as 5, indicating the medication was on hold. Review of the corresponding nurses note dated 06/10/23 at 8:48 P.M. revealed the medication was held pending declot of PICC. The morning and afternoon doses on 06/11/23 were also documented as 5. Review of a nurses note dated 06/11/23 at 10:34 A.M. revealed morning dose of cefazolin held due to waiting for Cathflo to arrive and a nurses note dated 06/11/23 at 1:49 P.M. revealed not able to give medication. Beginning with the night dose on 06/11/23, the medication was placed on hold. A total of six consecutive doses of cefazolin sodium was not administered between the night shift dose on 06/10/23 and the afternoon shift on 06/12/23.
Additional review of the MAR revealed heparin sodium was documented as 9 for the night dose on 06/09/23. Review of the corresponding nurses note dated 06/10/23 at 12:23 A.M. revealed the medication was on order. The morning dose on 06/10/23 was documented as 9 and the corresponding nurses note dated 06/10/23 at 7:33 A.M. revealed no information on why the medication was not administered. The 06/10/23 afternoon dose was also documented as 9, with the corresponding nurses note dated 06/10/23 at 12:44 P.M. not indicating why the medication was not administered. On 06/10/23, the night dose was documented as 9 with no corresponding nurses note. On 06/11/23, the morning and afternoon doses were documented as 5. Review of a nurses note dated 06/11/23 at 10:07 A.M. revealed unable to give and on 06/11/23 at 1:41 P.M. revealed the medication was not administered due to a clotted PICC. On 06/12/23, both the morning and afternoon doses of heparin were documented as 9. Review of a nurses note dated 06/12/23 at 1:33 P.M. revealed the medication was not administered and waiting on clot buster. Further review of the MAR revealed the night dose on 06/12/23 and the morning dose on 06/13/23 were administered and heparin was then discontinued.
Further review of the MAR revealed Cathflo Activase, ordered on 06/10/23, had no administration documented on 06/10/23. On 06/11/23, the medication administration was documented as 9. Review of a corresponding nurses note, dated 06/11/23 at 1:48 P.M. revealed Registered Nurse (RN) on site attempted to give with no access. Made call to access RN. On 06/11/23, the MAR indicated no documentation for the Cathflo Activase (second order) administration. On 06/12/23, the medication was administered and a corresponding nurses note dated 06/12/23 at 8:30 P.M. revealed Cathflo administration successful and lumens flushed.
Additional review of nursing progress notes from 06/10/23, when Resident #65's PICC line was initially noted to be clotted, through 06/12/23, when PICC line access was reestablished, revealed no additional information related to interventions to reestablish PICC line access.
Interview on 07/13/23 at 9:19 A.M. of the Director of Nursing (DON) confirmed Resident #65 had a PICC line upon admission for the administration of IV antibiotics related to pneumonia. The DON stated, while Resident #65 had a physician order for heparin sodium flushes, the order was a general order generated with PICC line usage, but based on standard of practice, would not have been appropriate to use. The DON stated the pharmacy would not have even filled the order because it was not clinically indicated. The DON verified heparin sodium had not been used to flush Resident #65's PICC line, as indicated per physician order, and the resident subsequently had a clotted PICC line. In addition, the DON confirmed the clotted PICC line was first discovered on 06/10/23. While an attempt was made on 06/11/23 to regain access to the PICC line, there was no other documentation the facility implemented any interventions to reestablish access to the line until approximately 8:30 P.M. on 06/12/23. As a result, Resident #65's antibiotic treatment was delayed, for a total of nine missed doses, and an extension of IV antibiotic treatment.
Interview on 07/13/23 at 11:02 A.M. of Quality Assurance Pharmacist (QAP) #400 revealed the facility had submitted the heparin sodium order as a profile order, meaning the facility did not want the medication sent but to be on file as an ordered medication. QAP #400 verified the pharmacy did not fill the order, however, the facility pulled a vial of the medication from their contingency supply for Resident #65 on 06/10/23. QAP #400 denied the pharmacy would not have filled a physician order because they determined a medication was not clinically appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and resident and staff interview, the facility failed to ensure medications were available for administration. This affected one (#36) of one residents reviewed for availability of medications. The facility census was 72.
Findings include:
Review of the medical record revealed Resident #36 was admitted on [DATE]. Diagnoses included peripheral vascular disease, anemia, unspecified atrial fibrillation, major depressive disorder edema, muscle weakness, chronic venous hypertension with ulcer of right lower extremity, and essential hypertension.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was cognitively intact.
Review of Resident #36's physician orders revealed an order dated 03/14/23 for the eye medication Systane Ultra Preservative Free (PF) Ophthalmic Solution 0.4-0.3% with instructions to instill two drops in both eyes three times a day for dry eyes.
Review of the July 2023 medication administration record (MAR) revealed Resident #36's Systane Ultra PF Ophthalmic Solution was coded on the MAR to see nurse's notes on 07/07/23 (afternoon), 07/08/23 (afternoon), 07/09/23 (morning and afternoon), 07/11/23 (morning and afternoon), and 07/12/23 (morning and afternoon).
Review of the MAR notes dated 07/07/23 through 07/12/23 revealed Resident #36's Systane Ultra PF Ophthalmic Solution was on order or awaiting delivery.
Interview on 07/10/23 at 2:36 P.M., with Resident #36 stated at times she received her eye drops and other times the nurses report the medication was on order.
Observation on 07/12/23 at 4:43 P.M., of the medication cart revealed Resident #36's Systane Ultra PF Ophthalmic Solution could not be located. Interview with the Director of Nursing and Clinical Nurse Manager Licensed Practical Nurse (LPN) #306 verified the medication was not available at that time.