Ohio Eastern Star Hlth Care Ctr The

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of facility policy, and review of McGeer's criteria, revealed the facility failed to follow antibiotic stewardship for two residents (#10 and #15) of seven residents reviewed for infection control. The facility census was 70.Findings include:1. Review of Resident #15's medical record revealed an admission date of 07/17/24 with diagnoses including acute respiratory failure with hypoxia, type two diabetes mellitus, major depressive disorder, unspecified dementia, and cognitive communication deficit.Review of Resident #15's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition.Review of Resident #15's progress note dated 01/09/26 revealed the nurse assessed a skin issue to the residents' right inner thigh. The area was hard to the touch, large in measurement, and raised with no discoloration. Resident #15 only reported pain in the area when it was touched. An additional progress note on 01/09/26 revealed the Certified Nurse Practitioner (CNP) gave a new order to start Cephalexin 500 milligrams (mg) one capsule twice a day for seven days for cellulitis.Review of Resident #15's infection tracker dated 01/09/26 revealed most questions were left unanswered including the type of infection, if the surveillance definition was met, if it was a reportable infection, her history, symptoms, onset date, and diagnostic testing. The only areas completed were responsible party notifications, new orders, and attached progress notes. The evaluation notes stated the resident remained with a lump however the antibiotic was completed and a Doppler and ultrasound were completed and negative for a deep vein thrombosis. The final question on the form was if the symptoms resolved and treatment was completed, to which there was a check mark and the answer, no.Review of Resident #15's physician orders dated 01/09/26 to 01/16/26 revealed an order for Cephalexin 500 mg one capsule twice a day. To start with bedtime dose on 01/09/26 and end upon rising on 01/16/26.Interview on 02/12/26 at 9:23 A.M. with MDS Nurse #120 revealed the facility was supposed to follow McGeer's criteria for infections. She verified Resident #15 did not meet McGeer's criteria for antibiotics and that there was no evidence the physician was notified of this. Review of the McGeer's criteria checklist for cellulitis, soft tissue or wound infections, dated 11/05/24, revealed at least one criterion must be met: either pus at the wound, skin, or soft tissue site; at least four of the following new or increasing signs or symptoms, heat (warmth) at affected site, redness (erythema) at affected site, swelling at affected site, tenderness or pain at affected site, serous drainage at the affected site; or at least one of the following: fever, leukocytosis, acute changed in mental status, or acute functional decline. 2. Review of Resident #10's medical record revealed an admission date of 09/25/19 with diagnoses including type two diabetes mellitus, major depressive disorder, hemiplegia and hemiparesis affecting left non-dominant side, and osteoarthritis.Review of Resident #10's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition.Review of Resident #10's progress note dated 02/06/26 revealed the resident had an open area from Moisture Associated Skin Damage (MASD) on her right buttock. The nurse also noted the resident's right index finger was reddened around the cuticle and slightly swollen at the end of the fingernail. Hospice was made aware and gave orders for Clindamycin.Review of Resident #10's infection tracker dated 02/06/26 revealed the resident had a soft tissue infection of the right buttock and suspected cellulitis of the right index finger. Symptoms included her right buttock was extremely red and excoriated and her right index finger was red and slightly swollen. No other symptoms were indicated and no other diagnostics were performed.Review of Resident #10's physician order dated 02/07/26 to 02/16/26 revealed an order for Clindamycin 300 milligrams (mg) three times a day.Interview on 02/12/26 at 9:23 A.M. with MDS Nurse #120 revealed the facility was supposed to follow McGeer's criteria for infections. She verified Resident #10 did not meet McGeer's criteria for antibiotics and that there was no evidence the physician was notified of this. Review of the McGeer's criteria checklist for cellulitis, soft tissue or wound infections, dated 11/05/24, revealed at least one criterion must be met: either pus at the wound, skin, or soft tissue site; at least four of the following new or increasing signs or symptoms, heat (warmth) at affected site, redness (erythema) at affected site, swelling at affected site, tenderness or pain at affected site, serous drainage at the affected site; or at least one of the following: fever, leukocytosis, acute changed in mental status, or acute functional decline. Review of the policy 'Antibiotic Stewardship/infection Control' revealed it was facility policy to implement an antibiotic stewardship program that promoted appropriate use of antibiotics while optimizing treatment of infections and reducing the possible adverse events associated with antibiotics.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and policy review, the facility failed to notify the physician when Resident #15 missed doses of medication and failed to notify the family/power of attorney (POA) and physician of Resident #74's transfer to the hospital. This affected two residents (#15 and #74) of 20 records reviewed. The facility census was 70.Findings include:
1. Review of Resident #15's medical record revealed an admission date of 07/17/24 with diagnoses including acute respiratory failure with hypoxia, type two diabetes mellitus, major depressive disorder, unspecified dementia, insomnia, and cognitive communication deficit.
Review of Resident #15's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition.
Review of Resident #15's physician order dated 11/05/24 revealed an order for Brillinta 90 milligrams (mg) twice a day.
Review of Resident #15's Medication Administration Record for 02/01/26 to 02/11/26 revealed Brillinta was not administered on 02/09/26 for either scheduled doses due to being unavailable. On 02/10/26 the 'upon rising' dose was administered late at 3:37 P.M. because it had been unavailable and the pharmacy had to send it.
Review of Resident #15's progress notes revealed no evidence the physician was notified of Resident #15's missing medication.
Interview on 02/11/26 at 1:35 P.M. with Registered Nurse (RN) #109 revealed she had been the nurse who called the pharmacy over the missing medication. She verified there was no evidence the physician had been notified of the missing doses.
2. Review of Resident #74's medical record revealed admission date 05/10/23 and discharge date [DATE] with diagnoses including but not limited to gastrointestinal hemorrhage, heart failure, and type two diabetes. The resident was a Full Code.
Review of Resident #74's quarterly minimum data set (MDS) dated [DATE] revealed intact cognition with a Brief Interview Mental Status (BIMS) score of 14 out of possible 15.
Review of Resident #74's care plan dated 09/27/25 revealed Resident #74 had ineffective breathing patterns related to shortness of breath at times.
Review of Resident #74's physician orders revealed an order dated 11/23/25 for a 2-view chest Xray.
Review of Resident #74's progress note dated 11/23/25 at 2:30 P.M revealed Resident #74's family was visiting when Resident #74 was noted to have increased confusion and complaining of left sided lung pain at times. An Xray was ordered with the results revealing Resident #74 had shallow breathing (hypoaeration of the lungs) and right atelectasis (partial or complete collapse of lung lobes). The facility's Certified Nurse Practitioner (CNP) #310 was notified of the Xray results and ordered an antibiotic. Resident #74's power of attorney (POA) was notified and did not want Resident #74 sent to the hospital.
Review of Resident #74's progress note dated 11/23/25 at 11:18 P.M. revealed Resident #74 was noted to be heard calling out for assistance. Registered Nurse (RN) #115 assessed Resident #74 with vital sign results including respirations 38 breaths per minute (normal ranges from 12 to 20 breaths per minute), heart rate 138 beats per minute (bpm) (normal ranges from 60 to 100 bpm), blood pressure 88/73 millimeters of Mercury (mmHg) (normal ranges around 120/80 mmHg), and temperature 97.6 degrees Fahrenheit (F) (normal ranges from around 97 degrees F to 99 degrees F). Emergency Medical Services (EMS) was notified for the transfer of Resident #74 to the hospital for further evaluation. The progress notes revealed no evidence the resident's family/POA or physician were notified of the hospitalization.
An interview on 02/12/26 at 10:07 A.M. with Licensed Practical Nurse Unit Manager (LPN UM) #15 confirmed there was no notifications documented for Resident #74's family/POA or the on-call physician when Resident #74 was transferred to the hospital on [DATE] at 11:18 P.M. LPN UM #15 stated even in an emergency the physician and family were to be notified, and the notifications were to be documented in the progress notes.
Review of the facility's undated policy titled, Procedure for notification of changes for resident, revealed the facility shall promptly notify the resident and/or the resident representative and his or her physician or delegate of changes in the resident's condition or status to obtain orders for appropriate treatment and monitoring and promote the resident's right to make choices about treatment and care preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to maintain Resident #56's privacy when a video monitor, monitoring his room, was kept in the common area. This affected one resident (#56) of one resident reviewed for privacy. The facility census was 70.Findings include: Review of Resident #56's medical record revealed an admission date of 01/03/26 with diagnoses including fracture of right pubis, unspecified dementia, severe protein-calorie malnutrition, depression, anxiety disorder, chronic kidney disease, and repeated falls. Review of Resident #56's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. Review of Resident #56's physician order dated 01/04/26 revealed a video monitoring device was to be in place for fall prevention.Observation on 02/10/26 at 9:16 A.M. of Resident #56's unit revealed when entering the unit through the door there was a main common area with several recliners facing the television. The television was on a wall with open windows into the dining room. A monitor was observed sitting on the ledge of the window on the left. On this monitor Resident #56 could be observed sitting in his chair in his room.Observation on 02/10/26 at 9:35 A.M. revealed the monitor remained in the same location, Resident #56 was observed sitting in his room. There were residents in the common area.Interview on 02/10/26 at 9:35 A.M. with Certified Nurse Assistant (CNA) #22 verified the observation. She reported they had a 'baby monitor' for Resident #56 due to his falls. She verified it could be seen by anyone in the common area. CNA #22 reported it could not be at the nurse's station because the distance was too far for the monitor to pick up. Observation on 02/11/26 at 10:05 A.M. revealed the monitor remained in the same location, there were two residents in the common area. Observation at 10:55 A.M. revealed Resident #56 could be observed in his bed on the monitor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure fall prevention strategies were in place for Resident #15 prior to a fall. This affected one resident (#15) of three residents reviewed for falls. The facility census was 70.Findings include: Review of Resident #15's medical record revealed an admission date of 07/17/24 with diagnoses including acute respiratory failure with hypoxia, type two diabetes mellitus, major depressive disorder, unspecified dementia, and cognitive communication deficit.Review of Resident #15's fall event dated 10/14/24 revealed she had a fall while transferring off the commode.Review of Resident #15's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition and required partial to moderate assistance with toileting hygiene and supervision or touching assistance with toilet transfers. Review of Resident #15's plan of care dated 07/10/25 revealed the resident was at risk for falls, accidents, and injury related to admitted from hospital due to fall at home diagnoses, and getting up and walking without asking for assistance. Interventions included keeping bed at safe height and walker near reach, offer to toilet in early morning and assist as needed, keeping bathroom door closed while elder is in room to not tempt her to go herself, personal items in reach and return to bed after meals.Review of Resident #15's progress note dated 07/11/25 revealed the resident was heard calling out for help. The resident was found by the nurse lying on the bathroom floor with blood to her posterior head. The resident stated they fell backwards losing balance and injuring her head. Direct pressure was applied to the area and the resident was assessed. The call light was not utilized prior to her fall, the resident indicated she forgot. The staff reported Resident #15 and their neighbor were both attempting to use the restroom unassisted after they visited each other. They assisted Resident #15 on to the commode with her walker and call light in reach and went to her neighbor to assist them. This is when the resident fell. The resident was sent to the hospital.Review of Resident #15's fall report dated 07/11/25 and closed 07/25/25 revealed the resident had an unwitnessed fall in the bathroom. The resident had been at the sink unsupervised after she had transferred herself off of the commode and not utilizing the call light. The resident reported a pain of six to her buttocks and back of the head. The staff were educated to stay with the resident even if she was using the commode due to the elder not utilizing the call light. Review of Resident #15's plan of care dated 12/30/25 revealed the resident was at risk for falls, accidents, and injury related to admitted from hospital due to fall at home diagnoses, and getting up and walking without asking for assistance. Interventions included keeping bed at safe height and walker near reach, offer to toilet in early morning and assist as needed, keeping bathroom door closed while elder is in room to not tempt her to go herself, personal items in reach, return to bed after meals, and added on 07/11/25 staff were educated to stay with the resident while using the commode due to the resident not utilizing the call light when in reach.Interview on 02/12/26 at 8:41 A.M. with Certified Nursing Assistance (CNA) #23 revealed staying with a resident while they were on the toilet depended on many factors including cognition and level of assistance. If they were a fall risk they would need someone to stay with them. They might stand outside the bathroom door with it cracked to give them privacy, but they would stay nearby.Interview on 02/12/26 at 11:00 A.M. with the Chief Executive Officer (CEO) verified the resident had been left alone on the toilet prior to her fall.

Based on observation, interview, and facility policy review, the facility failed to properly store medications for Resident #9. This affected one resident (#9) out of two residents reviewed for pain management and had the potential to affect two of fifteen residents the facility noted as independently ambulatory. The facility census was 70.Findings include:Review of Resident #9's medical record revealed an admission date of 07/27/24. Diagnoses included unspecified dementia, low back pain, unspecified chronic back pain, poly-osteoarthritis and type II diabetes with diabetic chronic kidney disease.Review of Resident #9's quarterly Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) of 05 indicating impaired cognition. Review of Resident #9's physician orders revealed an order for Tramadol (an opioid medication) 50 milligrams (mg) four times a day due upon rising, at noon, afternoon, and at bedtime.Review of the Resident #9's comfort care plan dated 01/19/26 revealed Resident #9 experienced low back pain, pain and had osteoarthritis with a goal that Resident #9 would voice comfort through the target date. Interventions included to administer medications per physician orders and monitor for side effects, report unrelieved complaints of pain and signs of discomfort to physician for adjustments in medication management, monitor for nonverbal signs of discomfort, and monitor for complaints of pain.Observation on 02/09/26 at 6:28 P.M. revealed a white pill in a medication cup sitting on the medication cart laptop keyboard. No nurse was noted on unit at time of observation.Interview on 02/09/26 at 6:31 P.M. with Licensed Practical Nurse (LPN) #123 confirmed the medication was sitting on keyboard of the medication cart and Registered Nurse (RN) #117 was supposed to administer the medication to Resident #9 prior to leaving. LPN #123 confirmed the medication was Resident #9's Tramadol.Review of Resident #9's Tramadol narcotic sheet confirmed Tramadol 50 mg was removed from the locked cabinet at 4:34 P.M on 02/09/26.Review of Resident #9's Medication Administration Record (MAR) revealed a note by RN #117 for the afternoon Tramadol on 02/09/26 at 4:35 P.M. that stated Not administered: administered at 6:30 P.M. by another nurse.Review of the facility's policy titled, Medication Administration dated 10/14/24 revealed a procedure to administer medication and remain with the resident while the medication is swallowed, never leave a medication in a resident's room without orders to do so. It noted staff were to return to the medication cart and document medication administration with initials on the MAR immediately after administering medication to each resident.

Based on observation, interview, review of menus, and facility policy review, the facility failed to prepare and serve appropriate portions of food during meal service. This deficient practice had the potential to affect all 14 residents residing in the Lily neighborhood. The facility census was 70.Findings Include:Review of the portion size chart kept at each neighborhood serving station revealed the following requirements for portion sizes: 4 oz for fruits, vegetables, regular meats, desserts, and pureed meats with bread worked in; 3 oz for pureed sides, desserts, meats, ground meats, and pureed fruits and veggies; and 5 1/3 oz regular, mech soft, pureed casseroles.Review of the weekly menu revealed there were no portion sizes noted for each food item.An observation on 02/11/26 from 11:30 A.M. to 11:50 A.M revealed Dietary Server (DS) #202 preparing to serve lunch meal for residents in the Lily neighborhood. Per the weekly menu, lunch meal consisted of chipped beef on toast, cooked carrots, cooked green beans, mandarin oranges, and as substitute meal cabbage soup and a tuna salad croissant. DS #202 began serving the mandarin oranges from the container into small dessert bowls using a black plastic tablespoon and placing one to two scoops of the mandarin oranges in each bowl. DS #202 placed serving utensils in each food item container including a 2-ounce (oz) ladle for the cabbage soup, a 1 oz ladle for the chipped beef, 4 oz scoop for the cooked carrots and the green beans, and a black plastic tablespoon for the tuna salad croissant. The lunch meal service began with DS #202 preparing a plate with chipped beef and toast. DS #202 served approximately three scoops of the chipped beef using the 1 oz ladle onto the four pieces of toast. DS #202 then prepared a small bowl of cabbage soup using the 2 oz ladle and placing approximately two scoops of the soup into the bowl, DS #202 prepared a tuna salad croissant using the black plastic tablespoon. DS #202 placed approximately three spoonfuls of the tuna salad on the opened croissant. Lunch service continued until all the residents were served the lunch meal.An interview on 02/11/26 at 12:00 P.M. with Dietary Director (DD) #300 revealed the serving utensils for each food item should include: 4 oz of fruit or vegetables, regular meats and desserts.An interview on 02/11/26 at 12:06 P.M. with DS #202 confirmed the incorrect serving utensils were used when serving the lunch meal. DS #202 stated, I don't measure the portions; I just know what each person eats.Review of the undated facility policy titled Portion Control revealed Individuals will receive the appropriate portions of food as outlined on the menu. Control at the point of service is necessary to assure that accurate portion sizes are served.

Based on observation, interview, and facility policy review, the facility failed to store food in a sanitary manner and failed to maintain sanitary conditions while serving food. This deficient practice had the potential to affect all residents residing in the facility, who received meals from the kitchen. The facility census was 70.Findings Include:1. An observation on 02/10/26 at 7:57 A.M. revealed in the reach-in freezer there was an opened cardboard box of exposed frozen egg patties in an opened plastic bag, an opened cardboard box of exposed frozen pre-made biscuits in an opened plastic bag, and an opened cardboard box of exposed beef patties in an opened plastic bag.
An interview on 02/10/26 at 7:45 A.M. with dietary cook (DC) #208 confirmed the opened cardboard box of exposed frozen egg patties in an opened plastic bag, the opened cardboard box of exposed frozen pre-made biscuits in an opened plastic bag, and the opened cardboard box of exposed beef patties in an opened plastic bag. DC #208 stated the plastic bags should be closed and the box should be closed after being opened for use so as not to expose the food items.
Review of the facility's policy titled Food Labeling, Dating, and Expiration, dated 02/28/20, revealed frozen food must be packaged and stored within the freezer in such a way as to protect and preserve the integrity and quality of the food. Food shall be discarded at an earlier date if it is determined that the food quality is compromised in any way.
2. Observation on the [NAME] unit on 02/11/26 at 11:40 A.M. revealed Housekeeper #204 walked into satellite kitchen with a long ponytail and no hairnet; she began standing near the prepared food. Near the door of the kitchen was a sign noting to wear a hairnet in entering kitchen.
Interview on 02/11/26 at 11:50 A.M. with Housekeeper #204 confirmed she forgot to put a hairnet on prior to going into kitchen.
Review of the undated facility's policy titled, Sanitation and Infection Control Employee Hygiene for Food Safety, revealed all employees will wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and facility policy review, the facility failed to maintain infection control during wound care for Resident #50, failed to implement Enhanced Barrier Precautions (EBP) for two residents. These deficient practices affected one resident (Resident #50) out of four residents reviewed for pressure ulcers and affected two residents (Residents #56 and #78) out of five residents reviewed for transmission based precautions. The facility census was 70.Findings Include:
1. Review of Resident #50's medical record revealed an admission date of 07/15/25 with diagnoses including but not limited stage four (IV) sacral pressure ulcer with osteomyelitis, type two diabetes mellitus, high blood pressure, and chronic pain.
Review of Resident #50's quarterly Minimum Data Set (MDS) dated [DATE] revealed cognitive impairment with a Brief Interview Mental Status (BIMS) score of 10 out a possible 15 and required staff assistance with self-care and mobility.
Review of Resident #50's physician orders revealed an order for wound treatment for a Stage IV sacral pressure ulcer including daily dressing changes with Silvercel rope packed in the wound and covered with a sacral foam dressing.
An observation on 02/11/26 at 9:24 A.M. revealed the Director of Nursing (DON) completing the sacral wound dressing change for Resident #50. The DON removed the Silvercel sheet from the package and used scissors, removed from her scrubs pocket, to cut the amount of Silvercel required to pack Resident #50's sacral wound. The DON did not clean or sanitize the scissors prior to cutting the clean SiIvercel sheet. The DON took the piece of Silvercel and packed Resident #50's wound and covered with a sacral foam dressing.
An interview on 02/11/26 at 9:30 A.M. with the DON confirmed the scissors were not cleaned prior to cutting the Silvercel sheet for packing of Resident #50's sacral wound.
Review of the facility's policy tilted Infection Control Policy revised March 2024 revealed environmental cleaning and disinfection including cleaning/disinfection of resident care equipment, including shared equipment.
2. Review of Resident #78's medical record revealed an admission date of 01/27/26 with diagnoses including but not limited to gastrostomy, dysphagia, adult failure to thrive, and depression.
Review of Resident #78's admission minimum data set (MDS) assessment dated [DATE] revealed Resident #78 received 51% or more of nourishment from enteral feeding.
Review of Resident #78's physician orders revealed orders to check the percutaneous endoscopic gastrostomy (PEG) tube placement every shift before medications and as needed (PRN), and an order to clean around the PEG tube site with gentle soap and water, pat dry daily and as needed. There was no evidence of orders related to Enhanced Barrier Precautions (EBP) or personal protective equipment (PPE) requirements.
Review of Resident #78's care plan revealed a care plan dated 02/02/26 for enteral feeding via PEG tube. There was no evidence of a care plan related to EBP or PPE requirements.
An observation on 02/10/26 at 10:15 A.M. revealed there was no notification sign for EBP or PPE available outside of Resident #78's room for use by staff while caring for Resident #78.
An interview on 02/10/26 at 10:35 A.M. with Licensed Practical Nurse (LPN) #150 confirmed Resident #78 did not have EBP notification sign and PPE outside of the room and there was no order for EBP, or a care plan developed for Resident #78 related to having a PEG tube in place.
Review of the EBP notification sign revealed providers and staff are to wear gloves and gown for the following high-contact resident care activities including device care or use: central line, urinary catheter, feeding tube, tracheostomy.
3. Review of Resident #56's medical record revealed an admission date of 01/03/26 with diagnoses including fracture of right pubis, unspecified dementia, severe protein-calorie malnutrition, depression, and anxiety disorder.
Review of Resident #56's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. Resident #56 had moisture associated skin damage (MASD).
Review of Resident #56's plan of care dated 01/26/26 revealed he had open MASD to the coccyx.
Review of Resident #56's physician order dated 01/09/26 revealed an order to apply zinc cream to an Abdominal pad (sterile dressing) and apply the pad to open MASD on the coccyx every shift.
Observation on 02/10/26 at 9:16 A.M. and on 02/11/26 at 10:05 A.M. and 1:35 P.M. revealed Resident #56 did not have Enhanced Barrier Precautions (EBP) in place.
Interview on 02/11/26 at 1:35 P.M. and 1:51 P.M. with RN #109 verified Resident #56 did not have EBP in place. She reported this was because his wound was not a pressure wound.
Interview on 02/11/26 at 3:36 P.M. with MDS Nurse #120 revealed the facility did not have an EBP policy.
Review of the CDC webpage 'Implementation of Personal protective equipment use in nursing homes to prevent spread of multidrug-resistant organisms' dated 04/02/24, and obtained at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html revealed nursing home residents with wounds were considered especially high at risk of the acquisition and colonization of multi-drug resistant organisms. The use of both gown and gloves for high-contact resident care activities was indicated.
Review of the facilities posted sign 'Enhanced Barrier Precautions' revealed everyone must perform hand hygiene when entering the room. Additionally, staff providing high contact care activities were to wear a gown and gloves while in the room. High contact care activities included: dressing, bathing, transferring, changing bed linens, brushing teeth, shaving, assisting with toileting, device care, wound care, and collecting soiled clothing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, review of medication prescribing information, facility policy and procedure review and interview, the facility failed to prevent a significant medication error from occurring involving Resident #75 related to the administration of prescribed narcotic pain medication.
Actual Harm occurred on 01/13/25 at 12:25 A.M. when Registered Nurse (RN) #201 administered Morphine Concentrate Solution, with a concentration strength of 100 milligrams (mg) per five milliliters (ml) (100 mg/5 ml), five milliliters (100 mg) to Resident #75, who had an order to receive 15 mg every eight hours. Following the identification of the significant medication error, the on-call physician was notified and Narcan (reversal agent) nasal spray was administered. As a result of the medication overdose, Resident #75 experienced tingling to the right side of the body with random spastic movements, chills (complaints of being cold) with clammy skin and diarrhea and required increased monitoring. This affected one resident (#75) of three residents reviewed for Morphine administration. The facility census was 73.
Findings Include:
Review of Resident #75's closed medical record revealed an admission date 01/11/25 with diagnoses including displaced fracture of the right femur, chronic obstructive pulmonary disease (COPD), and high blood pressure. The resident was discharged home on [DATE].
Review of Resident #75's signed physician orders revealed an order dated 01/11/25 for Morphine Immediate release tablet 15 mg give one tablet every eight hours for pain. However, due to the medication being unavailable on 01/12/25 an order was obtained for Morphine (liquid) solution 10mg/5ml give 0.75 ml to equal 15 mg every eight hours.
Review of the pharmacy's Authorization for Accessing Controlled Substances from Medication Starter Kit form dated 01/12/25 at 7:46 A.M. revealed Licensed Practical Nurse (LPN) #203 requested authorization to remove Morphine Sulfate solution 20mg/ml from the starter kit for Resident #75. Authorization was received from pharmacy at 8:56 A.M. and LPN #203 removed the Morphine Sulfate 20mg/ml bottle (a 15 ml bottle) for Resident #75 and implemented a narcotic count sheet for the Morphine Sulfate solution. The narcotic sheet did not include the Morphine order.
Review of Resident #75's Morphine Sulfate narcotic count sheet dated 01/12/25 revealed the sheet reflected the Morphine Sulfate (20 mg/ml) with 15 ml as the beginning amount of Morphine in the bottle. The following entries were documented:
a. On 01/12/25 at 9:24 A.M. RN #333 administered 0.75 ml of Morphine Sulfate to Resident #75 leaving 14.25 ml of Morphine in the bottle.
b. On 01/12/25 at 4:06 P.M. RN #333 administered 0.75 ml of Morphine Sulfate to Resident #75, leaving 13.50 ml in the bottle.
c. On 01/13/25 at 12:25 A.M. RN #210 administered five (5) ml of Morphine Sulfate.
Review of Resident #75's progress note dated 01/13/25 at 2:45 A.M. and authored by RN #201 revealed RN #201 had administered an incorrect dose of Morphine Sulfate at 12:25 A.M. The resident's current order indicated Morphine 10mg/5ml with a dosage of 0.75 ml to be administered. However, RN #201 had given Resident #75 five (5) mls of Morphine Sulfate which equaled 100 mg of Morphine Sulfate from the bottle it was obtained from. RN #201 noted the available bottle of Morphine was 20 mg/ml which did not match the current order of Morphine 10 mg/5 ml with the administration of 0.75 mls. However, the order (10mg/5 ml give 0.75 ml to equal 15 mg) was not accurate as the administration of 0.75 ml would result in the resident receiving 1.5 mg of Morphine Sulfate and not 15 mg.
The progress note included the on-call physician was notified (of the medication error/overdose). At 12:55 A.M. Resident #75 received Naloxone (Narcan) four mg intranasally. RN #201 continued to monitor Resident #75 and obtained vital signs throughout the shift. At 1:05 A.M. Resident #75 reported tingling to the right side and at 1:15 A.M. Resident #75 experienced random spastic movements. The on-call physician was notified of the observations with no new orders implemented. At 1:45 A.M. Resident #75 had a large bowel movement with clammy skin noted. Resident #75 requested more blankets due to feeling cold. Resident #75's vital signs at 4:00 A.M. included: temperature 98.2, blood pressure 154/64, pulse 93, respirations 16 and blood oxygen (SP02) level 98% at room air.
Review of Resident #75's January Medication Administration Record (MAR) revealed on 01/13/25 at 1:05 A.M. LPN #232 administered one spray of Naloxone (Narcan) four mg nasally to Resident #75 with results being effective with no respiratory distress observed.
Further review of the medical record revealed the Morphine Solution order was clarified on 01/13/25 to administer Morphine Solution 20mg/ml, administer 0.75 ml (15 mg) every eight hours.
Review of the January 2025 MAR revealed the Morphine was administered every eight hours until 01/14/25 at 8:00 A.M. when the pharmacy delivered Morphine 15 mg Immediate Release tablets and the Morphine concentrate was discontinued.
The facility did not have an investigation regarding the significant medication error involving Resident#75 and the administration of 100 mg of Morphine.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #75 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 out of 15. The assessment revealed Resident #75 required assistance from staff to complete activities of daily living (ADL) tasks including transfers, dressing, and medication administration. Further review revealed Resident #75 had pain requiring daily administration of pain medication.
Interview on 02/25/25 at 10:30 A.M. with RN #333 revealed on 01/12/25 Resident #75 had been administered the Morphine Sulfate concentrate 0.75 ml which equaled 15 mg of Morphine at 9:24 A.M. and at 4:06 P.M. (The Morphine bottle the medication was obtained from contained 20 mg per every one ml).
Interview on 02/24/25 at 4:25 P.M. with RN #201 confirmed she administered Resident #75 100 mg of Morphine Sulfate on 01/13/25 at 12:25 A.M. RN #201 stated the only part of the order that was read was the five ml. RN #201 stated she did not check the order against the bottle of Morphine prior to administration and only questioned the order when RN #201 was signing the narcotic count sheet and realized the two prior doses had only been recorded as 0.75 ml of Morphine administered. RN #201 stated she administered the Morphine in a cup (Morphine concentrate is to be dosed with an included syringe, measured in 0.1 ml increments from 0.1 ml to1.0 ml) Once RN #201 realized the mistake she notified LPN #232 and compared the bottle of Morphine against the current order. The on-call physician was notified and LPN #232 administered Naloxone (Narcan) four mg to Resident #75. RN #201 stated she was responsible to provide one on one care with Resident #75 throughout the shift to monitor the resident's vital signs and observe for any negative outcome.
During the onsite investigation, attempts to reach LPN #203 were unsuccessful and no return calls were provided.
Interview on 02/24/25 at 2:06 P.M. with Pharmacist #118 revealed the facility had requested an authorization to remove Morphine from the emergency medication dispenser at 7:47 A.M. on 01/12/25. At 8:41 A.M. the pharmacy received the physician script for Morphine Concentrate Solution 100mg/ml (20mg/ml) administer 0.75 ml to equal 15 mg every eight hours for pain and granted authorization to the facility to remove the Morphine. The order for the Morphine Solution was temporary until the Morphine 15 mg (oral) tablets were delivered to the facility. Pharmacist #118 stated the administration of 5 ml of Morphine was a significant medication error resulting in Resident #75 receiving 100 mg of Morphine instead of the prescribed 15 mg.
Interview on 02/24/25 at 3:15 P.M. with the Chief Executive Officer (CEO) confirmed the facility did not complete an in-depth investigation at the time the medication error occurred but were currently completing one. The CEO stated the Director of Nursing had provided education to RN #201 and LPN #203 for the importance of accuracy when implementing new orders, not practicing the 6 Rights of medication administration and to question an order if the order didn't seem correct. However, the facility was unable to provide written evidence of this education. The CEO revealed DON #500 was no longer employed by the facility and had since resigned.
Review of RN #201's personnel file revealed a hire date 10/29/24 with an Employee Coaching form dated 01/13/25 issued by the previous Director of Nursing (DON #500), addressing the medication error which occurred on 01/13/25. The coachable form was issued regarding resident safety where an incorrect dose of pain medication was administered to Resident #75.
Review of the facility undated policy titled, Medication Administration revealed Safely and accurately administer physician-ordered medication to each resident. Remember the six Rights of correct medication administration - Right Resident, Right Drug, Right Dose, Right Dosage Form, Right Time, and Right Route.
Review of the Federal Drug Administration Highlights for Prescribing Information- Morphine Sulfate Solution revealed a warning for risk of medication errors as Morphine Sulfate Solution was available in 10 mg per five ml, 20 mg per five ml and 100 mg per five ml (20 mg/ml) concentrations. The 100 mg per five ml (20 mg per ml) concentration was indicated for use in opioid tolerant patients only. Take care to avoid dosing errors due to confusion between different concentrations and between milligrams and milliliters, which could result in accidental overdose and death.
Further review under warnings and precautions revealed to use caution when prescribing, dispensing, and administering Morphine Oral Solution to avoid dosing errors due to confusion between different concentrations and between mg and mL, which could result in accidental overdose and death. Use caution to ensure the dose is communicated clearly and dispensed accurately. Always use the enclosed calibrated oral syringe when administering Morphine Oral Solution 100 mg per 5 ml (20mg/ml) to ensure the dose is measured and administered accurately. Serious adverse reactions include respiratory depression, respiratory arrest, shock and cardiac arrest. Other adverse reactions may include sweating, tremors, agitation, low blood pressure.
Review of the information located on the website narcan.com revealed naloxone, the acting ingredient in Narcan nasal spray competes with opioids to bind with the same receptors in the brain, reversing the effects of an opioid overdose in two to three minutes.
This deficiency represents non-compliance investigated under Complaint Number OH00162170.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of the facility assessment, the facility failed to appropriately revise and implement individualized treatment and services to ensure residents, who displayed behaviors and/or were diagnosed with dementia received the appropriate treatment and services to attain or maintain their highest practicable physical, mental and psychosocial well-being. The facility failed to appropriately address Resident #73's dementia-related behaviors. This affected one (Resident #73) of three residents reviewed for dementia. The facility census was 71.
Findings include:
Review of the medical record revealed Resident #73 was admitted on [DATE] and expired on [DATE] with diagnoses that included vascular dementia, anxiety disorder, depression, and dysphagia.
Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 had moderately impaired cognitive skills. The MDS also revealed Resident #73 had verbal behaviors directed towards others.
Review of the physician orders revealed Resident #73 was ordered Ativan (antianxiety) 0.5 milligram (mg) tablet by mouth every six hours as needed and Ativan, Benadryl, Haldol (ABH) gel (for agitation) 0.5 milliliter (ml) topically as needed every six hours from [DATE] to [DATE]. Review of the medication administration record (MAR) revealed Resident #73 had been administered ABH gel on [DATE] at 7:57 P.M. and it was somewhat effective. A progress note dated [DATE] at 12:27 A.M. revealed Resident #73 was yelling at staff and making rude comments. Resident #73 was also arguing with and touching other residents. This caused increased agitation among the other residents. Review of the MAR revealed Resident #73 was not administered as needed Ativan.
Review of the Facility Assessment updated on [DATE] revealed the facility accepted and provided care for mental and behavioral health residents with psychosis, impaired cognition, mental disorder depression, bipolar disorder, schizophrenia, anxiety disorder, behavior that needs interventions, and Behavioral and Psychological Symptoms of Dementia (BPSD). This included common diagnoses of Alzheimer's disease and non-Alzheimer's dementia. The number/average or range of residents over the past year with behavioral health needs was two. Those with physical behavioral symptoms directed towards others was one and those with verbal behavioral symptoms directed towards others was two. The assessment revealed education about dementia care included providing care for a person living with dementia that focused holistically on the needs of the resident living with dementia as well as the other residents in the nursing home annually and orientation. Education for caring for a person with Alzheimer's or other dementia by supporting residents through the implementation of individualized approaches to care (including direct care and activities) directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities was ongoing and completed annually.
Review of the MAR revealed Resident #73 was administered Ativan 0.5 mg as needed on [DATE] at 11:53 A.M. The Ativan was somewhat effective. A progress note dated [DATE] at 2:42 P.M. revealed Resident #73 went into another resident's room but came back out into the hallway. The MAR did not reveal as needed ABH gel was administered.
Physician orders revealed Resident #73 was ordered ABH gel 0.5 ml topically every six hours as needed from [DATE] until [DATE]. A progress note dated [DATE] at 10:54 A.M. revealed Resident #73 followed an activities staff member into another resident's room. The nurse was able to redirect Resident #73 out of the room. The MAR revealed Resident #73 was administered as needed ABH gel on [DATE] at 11:34 A.M. The as needed ABH gel was effective.
A plan of care dated [DATE] revealed Resident #73 demonstrated behaviors such as yelling at staff, attempting to hit staff, slamming her door, and attempting to go out the doors. Interventions included intervening or providing redirection, providing calming activities and one on one as needed.
A progress note dated [DATE] at 6:39 P.M. Resident #73 followed the nurse into another resident's room. Resident #73 was able to be redirected. A progress note dated [DATE] at 3:42 P.M. revealed Resident #73 went into another resident's room and shut the door. The nurse went in and found Resident #73 attempting to open the closet door in the other resident's room. Resident # 73 eventually walked out of the other resident's room. Resident #73 went into other resident rooms at 3:56 P.M. and 4:00 P.M. Staff were able to get Resident #73 to return to her own room.
A progress note dated [DATE] at 4:50 P.M. revealed the nurse called Viaquest (company that specializes in the mental and behavioral health treatment for residents at nursing facilities) and left a message. Resident #73's daughter was notified Resident #73 was attacking staff, kicking doors, attempting to leave the unit, and entering other residents' rooms. At 5:02 P.M. Resident #73's daughter arrived at the facility. A progress note dated [DATE] at 5:11 P.M. revealed a Certified Nurse Practitioner (CNP) from Viaquest called and left a message with new orders for Haloperidol Lactate (to treat acute agitation) two milligrams (mg) twice a day for 14 days and Haloperidol Decanoate (long-acting form of Haloperidol) 50 mg for four weeks with a dose to be administered immediately. At 5:16 P.M. another CNP from Viaquest called and suggested a pink slip (emergency hospitalization for a mentally ill individual who may be a harm to themselves or others) would be faxed to the facility. Review of the MAR revealed as needed ABH gel was not applied on [DATE] until 5:26 P.M. and was somewhat effective. A progress note dated [DATE] at 5:40 P.M. revealed Resident #73's daughter reported Resident #73 was in a calmer state and was sitting in recliner. Resident #73's daughter stated she was returning to work and could be called if anything else was needed. Resident #73 received the Haloperidol one ml injection prior at 5:45 P.M. prior to Resident #73's daughter leaving.
Review of the Ohio Department of Mental Health and Addiction Services Application for Emergency admission form (DMHAS-0025) dated [DATE] at 5:28 P.M. revealed the name of the psychiatric hospital was left blank. The form was marked Resident #73 represented a substantial risk of physical harm to others as manifested by evidence of recent homicidal or other violent behavior, evidence of recent threats that place another in reasonable fear of violet behavior and serious physical harm, or other evidence of present dangerousness. The form was also marked that Resident #73 represented a substantial and immediate risk of serious physical impairment or injury to self as manifested by evidence that the person is unable to provide for and is not providing for the person's basic physical needs because of the person's mental illness and that appropriate provision for those needs cannot be made immediately available in the community. Resident #73 would benefit from treatment in a hospital for mental illness and is in need of such treatment as manifested by evidence of behavior that creates a grave and imminent risk to substantial rights of others or self. The Statement of Belief on the form instructed that the belief for why hospitalization was necessary had to be documented. The Statement of Belief was signed by Viaquest CNP and revealed Resident #73 had recurrent aggression amongst staff. Resident #73 was physically aggressive and attacking staff (kicking, scratching, punching, etc.). Resident #73 was unable to be consoled or redirected by staff. It is the provider's recommendation that Resident #73 be sent out for further evaluation and treatment.
The next progress note dated [DATE] at 1:00 P.M. revealed Licensed Practical Nurse (LPN) #100 and the Director of Nursing (DON) pulled Resident #73's daughter aside and advised the daughter of the plan to send Resident #73 to the emergency department for a psychological evaluation and admission to psychiatric hospital to get treatment. Resident #73 would need urine analysis and blood work to rule out anything acute before the psychiatric hospital would admit Resident #73. It was explained that Resident #73 was a danger to staff and other residents. The paperwork including a pink slip, orders, code status, and face sheet was given to Resident #73's daughter. On [DATE] at 1:30 P.M. Resident #73 left the facility with the daughter to go to the emergency department for psychiatric evaluation.
A progress note dated [DATE] at 9:50 P.M. revealed Resident #73 returned to the facility due to not meeting the criteria for admission to a psychiatric hospital.
A progress note dated [DATE] at 12:00 P.M. revealed a meeting was held with Resident #73's daughter. Concerns with Resident #73 aggressive behavior towards staff and aggression starting to progress towards other residents were discussed. Resident #73's daughter made it clear she did not want Resident #73 sent to psychiatric hospital and wished to collaborate with Viaquest and Hospice for medication management. Resident #73 had been resting in bed with eyes closed since returning from the emergency department. Resident #73's daughter stated she would take off work to help with the transition to new medications. The resident's daughter also stated her biggest desire was communication from staff when Resident #73 was combative or staff were able to apply medication. The floor nurse was instructed to communicate with Resident #73's daughter any time Resident #73 became combative or aggressive.
On [DATE] at 3:11 P.M. new orders were received from Viaquest CNP to discontinue all Haloperidol orders, increase sertraline (antidepressant) cream to 50 mg topically daily, to start Risperdal (to treat behavioral disorders) 0.5 mg topically twice a day, discontinue ABH gel for agitation once Risperdal was started, and start Ativan (to treat anxiety) one mg intramuscular (IM) twice a day for 14 days. On [DATE] at 12:13 P.M. new orders were received from hospice to discontinue sertraline, the scheduled Ativan, and Risperdal cream. A new order was received for Ativan, one mg every hour as needed. On [DATE] at 1:15 P.M. Resident #73 was absent of vital signs.
Interview on [DATE] at 9:45 A.M. with daughter of Resident #73 revealed Resident #73 was not always administered the as needed medication for behaviors. The resident's daughter stated she had told the facility to notify her when Resident #73 had behaviors that could not be controlled or if Resident #73 refused medication. Resident #73's daughter felt that she could have assisted with deescalating the behaviors and get Resident #73 to agree to the as needed medication.
Interview on [DATE] at 12:13 P.M. the DON revealed Resident #73 had become more aggressive with staff, and other residents could be in danger. The DON verified Resident #73 was not transported to the hospital for evaluation until [DATE] around 1:30 P.M. which was 20 hours after the pink slip was obtained. The DON stated the pink slip was obtained after the DON had left for the day and was not addressed until the next day. The DON also verified there was no documentation of behaviors after Resident #73 was given ABH gel on [DATE] at 5:26 P.M. and Haloperidol lactate on [DATE] around 5:30 P.M. The DON did not supply any documentation of additional interventions, including the intervention of one-on-one that was listed in the care plan, being put in place to keep Resident #73 and other residents safe on [DATE] and [DATE] when Resident #73 was transported to the hospital. The DON verified he was unfamiliar with how a pink slip worked. The DON verified the facility did not have a policy for pink slips or emergency discharges.
Interview on [DATE] at 2:38 P.M. LPN #100 revealed Resident #73's behaviors were becoming worse on [DATE], and Resident #73 was biting staff. LPN #100 verified Resident #73 never harmed other residents but did go into other resident rooms. LPN #100 verified as needed medication was not always administered when Resident #73 had behaviors because the medication had to be gel or IM medication. LPN #100 also stated that none of the as needed medication worked anyway. LPN #100 stated the transfer to the hospital was delayed because she was unsure if the facility had to find a psychiatric hospital prior to Resident #73 being sent to the local hospital. LPN #100 verified she was unfamiliar with how a pink slip worked.
Interview on [DATE] at 2:44 P.M. LPN #101 revealed she was working day shift on [DATE] and [DATE]. LPN #101 verified she had obtained a pink slip for Resident #73 on [DATE] because Resident #73 was combative and attacking the staff. Resident #73 went into other resident rooms and would kick at other residents if they walked past her. (Review of the medical record revealed no documentation of Resident #73 being aggressive towards other residents). LPN #101 stated Resident #73 would not take as needed medication, so it was not administered. LPN #101 verified as needed medication was administered on [DATE] when Resident #73's daughter came to the facility. LPN #101 stated her shift ended at 6:00 P.M. on [DATE] and she did not know if Resident #73 continued to have behaviors that evening. LPN #101 also stated she could not recall if Resident #73 had behaviors the morning of [DATE] prior to being sent to the hospital for evaluation. LPN #101 stated there was a delay in sending Resident #73 to the hospital because the facility needed to find a psychiatric hospital that would take Resident #73. LPN #101 verified they were unfamiliar with how a pink slip worked.
This deficiency represents non-compliance investigated under Complaint Number OH00160152.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure Resident #67 who was elopement risk did not leave the facility unsupervised. This affected one resident (#67) of three residents reviewed for elopement. The facility census was 71.
Findings include:
Review of the medical record for Resident #67 revealed an admission date of 10/17/23 with diagnoses including dementia, pain, insomnia, depression, hyperlipidemia, and anxiety.
Review of Resident #67's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had a severe cognitive impairment and had wandered during the lookback period.
Review of Resident #67's plan of care initiated 11/12/23 and revised 08/19/23 revealed the resident was at risk for elopement due to wandering off of her neighborhood (unit), diagnosis of dementia, and being found outside of the neighborhood on 08/07/24. Interventions were dated 11/12/23 and included wanderguard to the right ankle, checking the placement of the wanderguard every shift, redirecting the resident when she is seen heading towards the exit door, and checking the wanderguard system and bracelet according to policy to ensure functioning.
Review of Resident #67's physician order dated 11/13/23 revealed an order for a wanderguard to the right ankle that needed checked every shift to ensure placement.
Review of Resident #67's progress note dated 08/07/24 revealed Resident #67 had been found wandering outside of the neighborhood. She was brought back without incident and her vitals were assessed. Resident #67 denied pain. She was anxious that morning and had been redirected multiple times, her wanderguard was in place.
Review of the facilities self-reported incidents (SRI) revealed an incident dated 08/07/24 at 2:31 P.M. of neglect or mistreatment. The initial note indicated at 2:00 P.M. the Administrator had been notified that Resident #67 had been found by the facilities general contractor walking by the construction trailer on the property. Maintenance Director #107 had received a call from the contractor at 1:29 P.M. notifying him of this. Maintenance Director #107 and Human Resources (HR) Assistant #120 went to retrieve the resident. HR Assistant #120 noted the resident to be physically fine and escorted her back to the building. She called the nursing staff on the walk back to inform them of their imminent return and the need for an assessment. The nurse had been unaware that the resident had been missing. The nurse completed the assessment and noted no injuries, she then called the power of attorney and nurse practitioner. The nurse manager initiated 15-minute checks for the resident for 24 hours following the incident. All staff were messaged and told to avoid going in and out of neighborhood doors unnecessarily for the next 24 hours. Resident #67 did not recall the incident but was dressed appropriately for the weather. The summary of the incident indicated on 08/08/24 they were able to access the camera and put together a timeline of the incident. At 1:15 P.M. the resident was observed at the back door of the [NAME] neighborhood which leads directly outside. She was observed to have turned the handle for 15 seconds to activate the alarm, and the door lock disengaged. She was observed at 1:17 P.M. walking through the north parking lot walking in the direction she was later found. At the same time (1:17 P.M.) Housekeeper #131 noted the alarm, she looked outside quickly and deactivated the alarm. Housekeeper #131 did not notify anyone of the alarm going off. Maintenance Director #107 was notified by the Contractor at 1:29 P.M. and HR Assistant #120 walked the resident back into the building at 1:33 P.M. When staff were interviewed it was discovered that nobody could hear the alarm at the front of the neighborhood. On 08/08/24 maintenance was asked to move the sound device box from the ceiling and mount it on the wall. The alarm was tested for appropriate volume along with all other door alarms in the neighborhood and it was ensured the alarms could be heard from all parts of the neighborhood. These changes were made in the other three sections of the long-term care neighborhoods. On 08/08/24 Housekeeper #131 was educated on turning off alarms without alerting nursing staff for them to do a headcount. A message was sent out by the administrator to all staff to inform nursing staff when turning off any alarm and for nursing staff to perform a headcount to ensure the safety of all residents. This information was repeated in the facility conclusion. The allegation was substantiated.
Review of Resident #67's 15-minute checks dated 08/07/24 revealed the resident was observed every 15 minutes from 08/07/24 at 2:00 P.M. to 08/08/24 at 2:30 P.M.
Review of the employee coaching form dated 08/08/24 revealed Housekeeper #131 was educated on an event that occurred on 08/07/24. Housekeeper #131 did not alert a nurse or aide that an alarm was going off for a fire door. She shut off the alarm, looked outside to see if she saw someone, and went about her job. Her education included the need to alert the nurse or aide of the alarm so they can evaluate the situation and make sure all residents are safe.
Review of the unlabeled message to staff from the Administrator dated 08/07/24 revealed staff were not to go through the [NAME] neighborhood to get to the parking lot or dumpster due to a resident that wanted to go home. The next message (later revealed to be on 08/08/24 by the Administrator) indicated if a door was alarming nursing should be alerted. Nursing staff was then to complete a visual headcount to ensure no residents were missing.
Review of the all-staff meeting dated 08/22/24 from 7:00 A.M. to 8:00 A.M. and 2:00 P.M. to 3:00 P.M. revealed the agenda included elopements there were 72 employees marked as being present by zoom without a signature and 106 had no indication that they were present or received the training.
Review of the after-action report by Director of Technology #142 undated, revealed it repeated the timeline indicated in the SRI. His recommendations included a louder audible signal on access-controlled egress doors, if staff member responding to a door that alarms the nurse on the neighborhood should be alerted, and looking for newer devices that could be used for tracking and triangulation of residents wearing a device like a wanderguard.
Interview on 09/04/24 at 11:10 A.M. with HR Assistant #120 revealed she had been with Maintenance Director #107 when he received a call from a construction worker. She reported she heard about the missing resident and went with him to get the resident. HR Assistant #120 reported the construction worker stayed with the resident while they were headed to her, and they were outside of the fenced in construction area when she arrived. The resident had been wearing a grey t-shirt, a zip-up sweater, long pants, and tennis shoes. HR Assistant #120 reported it had been warm that day so she asked the resident if she was hot and wanted to remove the sweater but the resident indicated she did not. She then walked the resident back into the building and the nurses and aides were informed of the incident. She reported the resident did not look injured or dirty.
Interview on 09/04/24 at 11:10 A.M. and at 2:16 P.M. with Maintenance Director #107 revealed he received a call from the contractor that there was a resident near the construction trailer on their campus. He and HR Assistant #120 went to get her and the contractor stayed with her until they arrived. The contractor explained that she had not been in the construction zone. The contractor had began walking her back to the facility when they arrived. He reported they found the alarm had not been loud enough for the nursing staff to hear and it had been adjusted.
Interview on 09/04/24 at 1:38 P.M. with Registered Nurse (RN) #111 revealed she had been the nurse on duty when Resident #67 eloped. She reported the alarm was not heard by nursing staff and she did not learn of the issue until they were bringing the resident back to the unit. She reported she did a complete assessment, her vitals were normal, she was uninjured and did not appear dirty or dusty.
Interview on 09/04/24 at 2:05 P.M. and 3:06 P.M. and email at 2:53 P.M. with the Administrator revealed they believed Resident #67 had walked down the out of use road to the construction trailer. The initial messages sent out on 08/07/24 and 08/08/24 was via their internal messaging system and went out to 227 employees. She reported the messaging system had informed her that all but 12 people reviewed the message but she was unable to identify which 12 people. Additional reinforcing of the education was given during the all-employee meeting on 08/22/24 and various departmental meetings thereafter.
This deficiency represents non-compliance investigated under Complaint Number OH00156739.

Based on record review and staff interview the facility failed to ensure nonpharmacological interventions were attempted and/or behaviors were documented prior to the administration of as needed psychotropic medications. This affected one (Resident #37) of five residents reviewed for unnecessary medications. The facility census was 68.
Findings include:
Review of the medical record for Resident #37 revealed an admission date of 06/02/21 with diagnoses including unspecified dementia, muscle weakness, depression, unspecified mood disorder, anxiety disorder, and cognitive communication deficit.
Review of the quarterly Minimum Data Set (MDS) assessment for Resident #37 dated 01/30/24 revealed the resident had severely impaired cognition and was coded for receiving antipsychotic, antianxiety, and antidepressant medications.
Review of the care plan for Resident #37 revised 02/07/24 revealed the resident had the potential for adverse or less than effective results from psychoactive medications. The resident was on antidepressants and medication for anxiety. Interventions included the following: consult with the physician about reductions and schedule per regulations, document on mood and behavior as needed, monitor for side effects of medication, report to the physician as needed.
Review of the physician's orders for Resident #37 revealed orders dated 02/28/24 to 03/12/24, 03/13/24 to 03/26/24, 03/27/24 to 04/09/24, 04/11/24 to 04/24/24, and 04/24/24 to 05/07/24, for Ativan/Benadryl/Haldol (ABH) gel to be applied topically every six hours as needed.
Review of the physician's orders for Resident #37 revealed an orders dated 02/28/24 to 03/12/24, 03/13/24 to 03/26/24, 03/27/24 to 04/09/24, 04/11/24 to 04/24/24, and from 04/24/24 to 05/07/24 for Ativan 0.5 milligrams (mg) one tablet every six hours as needed.
Review of the Medication Administration Record (MAR) for Resident #37 dated March 2024 revealed ABH gel was administered on 03/06/24 with no nonpharmacological intervention documented prior to administration. ABH gel was also administered on 03/15/24, 03/19/24, and 03/31/24 with no documentation indicating why the drug was needed and no nonpharmacological interventions. Ativan tablets were administered on 03/12/24, 03/18/24, and 03/26/24 with no nonpharmacological interventions documented. Ativan was also administered on 03/02/24, 03/09/24, and 03/16/24 with no documentation indicating why the drug was needed and no nonpharmacological interventions noted.
Review of the progress notes for Resident #37 dated 03/02/24 to 03/31/24 revealed they did not include documentation of behaviors or nonpharmacological interventions attempted on 03/02/24, 03/06/24, 03/09/24, 03/12/24, 03/15/24, 03/16/24, 03/18/24, 03/19/24, 03/26/24, and 03/31/24.
Review of the MAR for Resident #37 dated April 2024 revealed ABH gel was administered on 04/05/24 with no nonpharmacological intervention documented. ABH gel was also administered on 04/17/24 with no documentation indicating why the drug was needed and no nonpharmacological intervention documented. Ativan tablets were administered on 04/13/24 and 04/16/24 with no nonpharmacological intervention documented. Ativan was also administered on 04/05/24, 04/15/24, and 04/17/24 with no documentation indicating why the drug was needed and no nonpharmacological interventions documented.
Review of the progress notes for Resident #37 dated 04/05/24 to 04/17/24 revealed there was no documentation indicating behaviors or nonpharmacological interventions on 04/05/24, 04/13/24, 04/15/24, 04/16/24, and 04/17/24.
Review of the care plan for Resident #37 dated 04/22/24 revealed the resident demonstrated behaviors such as agitation and had diagnoses including mood disorder and anxiety. The resident yelled at staff during care and had agitation. Interventions included the following: call the resident's family when resident is anxious, assess and record changes in behaviors, report significant changes to staff and physician, educate and discuss with the family concerns and causal factors of behaviors.
Interview on 05/02/24 at 11:06 A.M. with the Director of Nursing (DON) confirmed the facility did not have documentation for behaviors or nonpharmacological interventions in conjunction with administration of as needed ABH gel and Ativan tablets for Resident #37.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of an owner's manual, and review of the facility policy, the facility failed to maintain the kitchen in a clean condition and failed to maintain kitchen equipment in proper working condition to prevent contamination and/or food borne illness. The had the potential to affect all residents in the facility. The facility census was 68.
Findings include:
1.Observation on 04/29/24 at 10:47 A.M. with [NAME] #169 revealed the bottom of two hot holding units were covered in food debris.
Interview on 04/29/24 at 10:47 A.M. with [NAME] #169 confirmed the bottoms of both units were not clean and they should be cleaned every two to three weeks.
Observation on 04/29/24 at 10:53 A.M. with [NAME] #169 and Dietary Manager (DM) #170 revealed there was a large thick frozen puddle of a dark brown and red substance on floor of walk-in freezer.
Interview on 04/29/24 10:53 A.M. with [NAME] #169 confirmed the substance on the floor of the walk-in freezer was a puddle of corned beef juice frozen to the ground.
Observation on 04/29/24 at 11:13 A.M. with [NAME] #169 and DM #170 revealed there was a sticky residue and sticker paper on plastic containers on the clean drying rack.
Interview on 04/29/24 at 11:13 A.M. with [NAME] #169 confirmed the presence of the sticky residue on the plastic containers and immediately took four small square containers to the dishwasher.
Review of the facility policy titled Main Kitchen Cleaning Checklist undated revealed staff tasks included detailed cleaning of the warming boxes, inside and out, and detailed cleaning of the coolers and freezers to be completed monthly.
2. Interview on 04/29/24 at 11:04 A.M. with DM #170 confirmed the facility had high temperature sanitizing dishwashers and the rinse water temperature to reach was 180 degrees Fahrenheit (F) when staff completed temperature checks. DM #170 also confirmed the facility had five satellite kitchens within the neighborhoods of the facility.
Observation on 04/29/24 at 12:10 P.M. of the [NAME] neighborhood dishwasher revealed DM #170 used a temperature strip to test the dishwasher hot rinse temperature. The strip was supposed to turn black when it reached 180 degrees F, but it only turned white and gray.
Observation on 04/29/24 12:15 P.M. revealed DM #170 used a thermometer to test the [NAME] neighborhood dishwasher hot rinse temperature again and the high temperature measured 162 degrees F.
Interview on 04/29/24 at 12:15 P.M. with DM #170 again confirmed the hot rinse temperature of the dishwasher should be 180 degrees F.
Observation on 04/29/24 at 12:17 P.M. revealed DM #170 tested the temperature of the [NAME] neighborhood dishwasher hot rinse a third time using a thermometer and it tested 152 degrees F.
Observation on 04/29/24 at 12:28 P.M. of the Lilly Neighborhood dishwasher revealed DM #170 tested the dishwasher hot rinse temperature with a thermometer and the high temperature read 163 degrees F.
Observation on 04/29/24 at 12:31 P.M. revealed DM #170 ran the Lilly neighborhood dishwasher a second time. Server #343 read the thermometer for the dishwasher hot rinse temperature and said it tested at 156 degrees F.
Observation on 04/29/24 12:36 P.M. revealed DM #170 ran the Lilly neighborhood dishwasher a third time. Server #343 read the thermometer for dishwasher hot rinse and said it tested at 147.6 degrees F.
Observation on 04/29/24 at 12:39 P.M. revealed DM #170 tested the [NAME] neighborhood dishwasher hot rinse temperature with a thermometer. When DM#170 attempted to read the thermometer, it was turned off.
Observation on 04/29/24 at 12:44 P.M. revealed DM #170 ran the [NAME] neighborhood dishwasher a second time. Server #341 read the thermometer and said the hot rinse temperature was 147 degrees F.
Observation on 04/29/24 at 12:47 P.M. revealed DM #170 ran the [NAME] neighborhood dishwasher a third time using a heat strip which did not turn black to indicate it was heated to 180 degrees F.
Interview on 04/29/24 at 12:53 P.M. with DM #170 confirmed it was the normal practice of the facility to test the dishwasher temperatures with heat strips and a thermometer.
Observation on 04/29/24 at 01:03 P.M. revealed DM #170 tested the dishwasher rinse temperature of the [NAME] neighborhood with a temperature strip. The temperature did not turn a different color which meant the rinse water did not reach 180 degrees F.
Observation on 04/29/24 at 01:06 P.M. revealed DM #170 ran the [NAME] neighborhood dishwasher a second time and tested the hot rinse water using a heat strip and a thermometer. The heat strip didn't change color and the thermometer read 147 degrees F.
Observation on 04/29/24 at 01:08 P.M. revealed DM #170 ran the [NAME] neighborhood dishwasher a third and tested the hot rinse water using a heat strip and a thermometer. The heat strip didn't change color and the thermometer read 148 degrees F.
Observation on 04/29/24 at 01:11 P.M. revealed DM #170 ran the [NAME] neighborhood dishwasher a fourth time and tested the hot rinse water using a heat strip and a thermometer. The heat strip didn't change color and the thermometer read 150 degrees F.
Observation on 05/01/24 at 12:10 P.M. of the [NAME] neighborhood dishwasher with DM #170 revealed the dishwasher hot rinse temperature was checked with a thermometer and it was 170 degrees F.
Observation on 05/01/24 at 12:16 P.M. of the [NAME] neighborhood dishwasher with DM #170 revealed the dishwasher hot rinse temperature was checked with a temperature heat strip and the dishwasher did not get to 180 degrees Fahrenheit.
Observation on 05/01/24 at 12:43 P.M. of the [NAME] neighborhood dishwasher with DM #170 revealed the dishwasher temperature was checked with a thermometer and it was 170 degrees F.
Review of the poster hanging on the wall of the [NAME] neighborhood kitchen regarding dishwasher temperature checks revealed employees should power on the thermometer, set to Fahrenheit and obtain water temperatures.
Review of the owner's manual for the dishwasher dated 03/01/22 revealed the wash temperature must be 155 degrees F minimum and the rinse temperature must be 180 degrees F minimum.
Review of the facility policy titled Culinary-Dishes dated March 2020 revealed the facility staff should operate dishwashers and related machinery in accordance with all manufacturers' guidelines.

Based on interview, record review, and review of the facility abuse policy the facility failed to ensure all employees were checked against the Nurse Aide Registry (NAR) for findings concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property. This affected four employees (Controller #217, Activities Assistant #234, Human Resources Director (HR) #235, and Dietary Aide (DA) #338) out of ten employees reviewed for proper screening procedures. This had the potential to affect all 59 residents residing at the facility.
Findings include:
Review of the personnel file for Controller #217 revealed her date of hire was 01/23/23, and there was no evidence in his personnel file that she was checked against the NAR prior to being employed at the facility.
Review of the personnel file for Activities Assistant #234 revealed her date of hire was 01/05/21, and there was no evidence in his personnel file that she was checked against the NAR prior to being employed at the facility.
Review of the personnel file for HR #235 revealed her date of hire was 10/26/22, and there was no evidence in his personnel file that she was checked against the NAR prior to being employed at the facility.
Review of the personnel file for DA #338 revealed her date of hire was 10/08/22, and there was no evidence in his personnel file that he was checked against the NAR prior to being employed at the facility.
Interview on 02/28/23 at 11:30 A.M. with HR #235 revealed she was not aware staff that were not State Tested Nursing Assistants (STNAs) or nurses were to be checked against the NAR to ensure they did not have a finding entered on the registry concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of property as required as a screening process to prevent abuse.
Interview on 02/28/23 at 11:35 A.M. with Chief Executive Officer (CEO) #252 revealed that she was not aware that all staff employed in a nursing facility must be checked against the NAR.
Interview on 03/01/23 at 7:36 A.M. with HR #235 and CEO #252 revealed they just ran all staff employed in the facility against the NAR.
Review of the undated facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property revealed the facility will not knowingly hire any individual who has been found guilty of abusing, neglecting, or mistreating other persons by a court of law; or have had a finding entered into the State NAR concerning abuse, neglect, mistreatment of residents, or misappropriation of their property. This facility will conduct employment background screening checks, reference checks and criminal conviction investigation checks on individuals making application for employment with this facility.

Based on observations, interview, and record review the facility failed to ensure the kitchen was clean and sanitary. This had the potential to affect all 59 residents that received meals from the facility. No residents were identified as receiving nothing by mouth.
Findings include:
A tour of the main kitchen on 02/27/23 from 8:00 A.M. through 8:30 A.M. with Dietary Manager #265 revealed the following:
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The small tabletop mixer had dried food splatter on the back of it.
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The reach-in refrigerator contained sliced ham, chili, and lunch meat that was not labeled or dated.
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The reach-in freezer contained pie crusts and angel food cake that was taken out of the original package without a label or date.
•
The walk-in refrigerator contained chopped garlic in a plastic container not labeled or dated.
Dieatary Manager #265 verified the above findings at the time of the observation.
Observation of the [NAME] Unit Pantry with Server #352 on 02/28/23 at 7:38 A.M. revealed the microwave was dirty, and in the reach-in freezer contained frozen omelets stored in a gallon-sized Ziploc bag with no label or date. Server #352 verified the findings at the time of the observation.
Observation of the [NAME] Unit Pantry with Server #421 on 02/28/23 at 7:47 A.M. revealed that microwave was dirty. Server #421 verified the findings at the time of the observation.
Review of the undated kitchen daily cleaning list revealed that equipment should be cleaned at least daily.
Review of the undated facility policy titled, Food Safety and Sanitation revealed the facility takes all precautions necessary in order to ensure healthy and safe dining standards. The daily cleaning task list was created and maintained by the culinary director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, observation, and interview the facility failed to appropriately clean the wound according to standards of care, and failed to maintain appropriate hand hygiene during the dressing change for Resident #42. This affected one resident (#42) out of two residents observed for wound care. The facility census was 59.
Findings include:
Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including a non-ST elevation myocardial infarction, coronary angioplasty, hemiplegia, and hemiparesis following cerebral infarction (stroke) affecting the left non-dominant side, type two diabetes, major depressive disorder, and bradycardia with pauses.
Review of the Minimum Data Set Assessment (MDS) 3.0 assessment dated [DATE] revealed Resident #42 was cognitively intact. Functionally, she required extensive assistance of two staff for bed mobility, dressing, toilet use, and personal hygiene. The resident had a stage II pressure ulcer (partial-thickness skin loss with exposed dermis) which was facility acquired.
Review of the plan of care dated 11/29/22 revealed Resident #42 had a stage II pressure ulcer to the right lateral heel. Interventions included: Moon boots (pressure reducing boots) to be worn while in bed if the resident allows; air mattresses; treatment per physician orders; encourage adequate nutrition and hydration; monitor percent of meals eaten; supplements per the physician's orders; closely monitor labs and nutrition assessments risks and weights as ordered; turn and reposition every two hours from side to side or as appropriate for condition; and pressure ulcer risk assessment at least quarterly.
Interview with Resident #42 on 02/27/23 at 8:45 A.M. revealed she did have a wound on her heel. The resident at the time denied feeling any pain in the wound and stated she does not have pain when the dressing is changed. She also stated the dressing was not changed daily but she thinks it is done on Fridays.
Interview with Licensed Practical Nurse (LPN) #211 on 02/27/23 at 9:30 A.M. revealed the resident does have a wound on her right heel which is a pressure ulcer.
Review of the physician's order dated 02/21/23 revealed an order for the right heel to be cleansed with wound cleanser, apply Silvercel (antimicrobial alginate dressing with silver) to the wound bed and cover with Mepilex (absorbent foam dressing), change every three days, and as needed. Monitor every shift and measure weekly.
Observation on 02/27/23 at 10:30 A.M. of the dressing change for Resident #42 revealed LPN #311 donned personal protective equipment per the facility protocol for wounds that were draining. Upon observation of this dressing change, LPN #311 appropriately washed her hands prior to removing the old dressing and put on clean gloves. She then proceeded to remove the right heel Kerlix gauze that was dated 02/24/23. She then removed the Mepilex and discarded the old dressing. She then proceeded to clean the wound with two-by-two gauze sponges and wound cleanser as ordered. Upon the cleaning of the wound, LPN # was observed at first wiping the outside of the wound and then she switched the sponge to a clean side and proceeded to clean the center of the wound. LPN #311 then obtained a second gauze sponge with wound cleanser on it and wiped the wound in a downward motion down the center of the wound and then wiped the outside of the wound with the other side of the sponge. After she wiped the outside edges of the wound the second time, she proceeded to wipe down the center of the wound with the used sponge. The wound bed was healthy pink color with epithelial tissue noted. It measured approximately 0.3 centimeters (cm) length by 0.5 cm width with a scant amount of serous drainage. LPN #311 then proceeded to discard the used gauze sponges and remove her gloves. She then donned a clean pair of gloves and proceeded to finish dressing the wound with the Silvercel to the wound bed and then covered it with the Mepilex and covered the whole area with a dry sterile pad and then wrapped the heel dressing with Kerlix gauze.
Interview with LPN #311 on 02/27/23 at 10:00 A.M. verified she cleansed the wound from the outside to the inside (dirty to clean) and she removed her dirty gloves during the dressing change but failed to wash her hands or use hand sanitizer prior to donning clean gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This affected one resident (#59) out of one resident who was prescribed pureed diets of 59 residents who consumed meals from the facility's kitchen. No residents were identified to receive nothing by mouth.
Findings include:
Review of the medical record for Resident #59 revealed an admission date of 12/15/22 with diagnoses including Alzheimer's disease, diabetes mellitus, depression, and anxiety disorder.
Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #59 had severely impaired cognition and required supervision with set-up only for eating.
Review of the physician's orders for February 2023 revealed on 02/14/23 nectar consistency liquids were ordered and pureed diet with sugar substitute was ordered on 02/28/23.
Interview on 03/01/23 at 11:20 A.M. Server #289 stated she already made Resident #59's tray because nursing wanted it and stated Resident #59 was on a mech soft diet.
Observation on 03/01/23 at 11:24 A.M. of Resident #59's tray coming out of Resident #59's room by State Tested Nursing Assistant (STNA) #342. Observation and interview with Server #289 and STNA #342 verified there were pieces of clam that were not pureed stuck to the side of the soup bowl. Server #289 stated that she did not puree Resident #59's soup.
Interview on 03/01/23 at 11:27 A.M. with Dietary Manager #265 verified the pieces of clam stuck to the side of the bowl and stated Resident #59's diet was changed last night because she pockets her food in her mouth.
Interview on 03/02/23 at 7:45 A.M. with Chief Executive Officer (CEO) #252 stated Resident #59 was on a pureed diet due to pocketing her food, so Resident #59 's food doesn't have to be pureed according to policy. CEO #252 verified the order was written pureed diet with sugar substitute with no mentioned that she pockets her food.
Review of the undated facility policy titled, Puree Diet Standard revealed for residents with a pureed diet as a result of a dysphagia diagnosis the diet will consist of pureed, homogenous, and cohesive foods. Food should be pudding-like; no coarse textures, raw fruits or vegetables, nuts, etc., are allowed. Any foods that require bolus fom1a1ion, controlled manipulation, or mastication are excluded. For residents with a pureed diet as a result of pocketing and who are not at risk for choking due to dysphasia can have texture to the pureed item with no larger particles of food than that as defined by the mince and moist diet. Mouth care should be performed after meal has been consumed.