Hall of Fame Rehabilitation and Nursing Center

Based on record review and interview, the facility failed to ensure Resident #34's urine specimens were sent to the laboratory and the results of the laboratory testing were acted upon to timely treat Resident #34's urinary tract infection. This finding affected one (Resident #34) of three residents reviewed for urinary tract infections (UTIs).

Findings include:

Review of Resident #34's medical record revealed the resident was admitted on 09/24/21 with diagnoses including hemiplegia, cerebral infarction and muscle weakness.

Review of Resident #34's Minimum Data Set (MDS) 3.0 assessment dated 05/26/23 revealed she exhibited moderate cognitive impairment.

Review of Resident #34's progress note dated 07/13/23 at 4:42 P.M. authored by Licensed Practical Nurse (LPN) #808 indicated the resident reported issues with urinary frequency and denied pain. A urine was sent for a urinalysis (UA) lab test to rule out a UTI.

Review of Resident #34's laboratory form dated 07/13/23 at 4:56 P.M. indicated the sample was canceled on 07/14/23 at 7:03 P.M. because the specimen collection date was greater than the acceptable specimen stability.

Review of Resident #34's progress note dated 07/16/23 at 6:49 P.M. authored by Registered Nurse (RN) Director of Nursing (DON) indicated the facility was still waiting on the UA lab test results.

Review of Resident #34's note dated 07/17/23 at 6:29 P.M. authored by RN DON indicated the facility was still waiting on the UA lab test results.

Review of Resident #34's progress note dated 07/21/23 at 6:05 P.M. authored by RN DON indicated the facility was still waiting on the UA lab test results.

Review of Resident #34's progress note dated 07/26/23 at 5:19 P.M. authored by LPN #808 indicated the nurse called the laboratory about the UA lab test results and the lab stated the specimen sample was contaminated. A stat order for another urine specimen for a UA lab test was obtained.

Review of Resident #34's laboratory profile form dated 07/27/23 at 1:40 A.M. revealed an order for an urine albumin/creatinine ratio.

Review of Resident #34's point click care (PCC) computer documentation revealed the urine albumin/creatinine ration was collected on 07/27/23 at 1:40 A.M. and completed on 07/27/23 at 9:57 A.M.

Review of Resident #34's progress note dated 07/27/23 at 10:57 A.M. authored by LPN #808 indicated the lab test results were sent to the physician and no new orders were obtained.

Resident #34's urine lab test result dated 07/27/23 revealed the wrong lab test completed for the resident as it should have been for a UA plus culture and sensitivity (C&S).

Review of Resident #34's physician orders revealed an order dated 07/29/23 to obtain a UA due to complaints of dysuria. The treatment administration records (TARS) revealed the order was documented as completed on 07/29/23 and 07/30/23.

Review of Resident #34's progress note dated 07/29/23 at 11:45 A.M. authored by RN DON indicated the laboratory company was called to pick up a urine specimen due to complaints of dysuria.

Review of Resident #34's progress note dated 07/29/23 at 3:18 P.M. authored by RN DON indicated the UA lab test results were received which was positive for leukocytes with moderate bacteria. The facility was waiting on the C&S lab test to determine the appropriate antibiotic to use for the UTI.

Review of Resident #34's progress note dated 07/30/23 at 2:39 P.M. authored by RN DON indicated bactrim antibiotic ordered for seven days.

Review of Resident #34's progress note dated 07/31/23 at 11:50 P.M. authored by RN #809 indicated she was called to the resident's room, and she appeared confused and not quite herself. Her blood pressure was 140/85 with a heart rate of 70 and respirations of 18 and a pulse oximetry of 95% (percent) on room air.

Review of Resident #34's change in condition progress note dated 08/01/23 at 5:50 A.M. indicated the resident had altered mental status and uncontrolled pain.

Review of Resident #34's progress note dated 08/01/23 at 2:00 P.M. indicated the hospital reported the resident was admitted for blurry vision, altered mental status and UTI.

Review of Resident #34's hospital paperwork dated 08/01/23 indicated the resident was treated for a UTI; however, she was found to be more confused and disoriented over the midnight with a headache and blurry vision in both eyes. She was admitted for a possible cerebrovascular accident (CVA or stroke).

Interview on 08/11/23 at 7:36 A.M. with RN DON indicated she sent Resident #34's urine specimen for a UA plus C&S lab test on 07/29/23 and she started the resident on antibiotics on 07/30/23.

Interview on 08/11/23 at 7:40 A.M. with LPN Assistant Director of Nursing (ADON) confirmed the facility had been having difficulty obtaining lab results from their current laboratory and was in the process of having a meeting with them.

Interview on 08/11/23 at 9:10 A.M. with Lab #810 indicated the facility sent an outdated urine specimen for Resident #34 and they were unable to use the urine for a UA plus C&S lab test on 07/13/23. She stated the order had to be canceled and the facility had to resend another urine. She stated new orders for a UA plus C&S lab tests were placed on 07/19/23 and 07/20/23. Lab #810 indicated on 07/26/23 an order was placed for a urine creatinine ratio lab test. She indicated they did not receive any additional urine specimens after 07/13/23 for a UA plus C&S lab test but the laboratory did receive a urine specimen for a creatinine test on 07/26/23 which was resulted on 07/27/23.

Interview on 08/11/23 at 9:35 A.M. with LPN #808 indicted he sent a urine specimen to the laboratory for Resident #34 on 07/13/23 and was unaware it was canceled. He said he had ordered an UA with C&S lab test on 07/26/23 and it was completed by the lab on 07/27/23 as an albumin/creatinine ratio lab test in error. LPN #808 stated he knew he put the lab test in as a UA plus C&S.

An additional interview on 08/11/23 at 9:43 A.M. with RN DON confirmed Resident #34's UA plus C&S lab test was ordered and sent to the lab on 07/13/23 and the facility was unaware the test was canceled on 07/14/23. She confirmed Resident #34's UA plus C&S lab test results were not obtained until another urine specimen was sent to the lab on 07/29/23 and the result of the lab test was obtained by the facility on 07/29/23 which delayed the resident's care for complaints of pain and dysuria.

This deficiency represents non-compliance investigated under Complaint Number OH00145202.

Based on observation and interview, the facility failed to serve food at a palatable temperature. This finding had the potential to affect 44 residents who receive meals from the kitchen. The facility census was 44.

Findings include:

On 07/21/23 at 7:22 A.M., a test tray was placed on the food serving cart and the cart left the kitchen to the first floor unit. Milk and orange juice were on top of the food serving cart with a large blue ice pack placed on top of the milk and juice.

Observation on 07/21/23 at 7:24 A.M. revealed the food serving cart arrived on the first floor and observation at 7:26 A.M. revealed staff began passing out the breakfast meal trays to residents in their rooms. The large blue ice pack was removed from the milk and juice and placed underneath of the plastic tub holding the milk and juice. Observations revealed all meal trays were delivered by 7:29 A.M.

A test tray was conducted on 07/21/23 at 7:34 A.M. with Registered Nurse (RN) Director of Nursing (DON) which consisted of eggs, toast, orange juice and milk. The orange juice had a holding temperature of 60 degrees Fahrenheit and the milk had a holding temperature of 62 degrees Fahrenheit.

Interview on 07/21/23 at 7:36 A.M. with the RN DON confirmed the orange juice and milk were not palatable and did not meet the required temperature.

Interview on 07/21/23 at 11:30 A.M. with Licensed Practical Nurse (LPN) Assistant Director of Nursing (ADON) #802 confirmed all 44 residents receive meals from the kitchen.

This deficiency represents non-compliance investigated under Complaint Number OH00144296.

3. Observations on 04/24/23 at 9:10 A.M. revealed the room of Resident #40 had a large hole in his wall by the head of his bed and the electrical outlet was hanging partial out of the wall.

On 04/24/23 at 10:50 A.M. an interview with Registered Nurse #836 verified there was a hole in the wall in the room of Resident #40.

On 04/24/23 at 12:21 P.M. an interview with Maintenance Director #818 stated the wall in the room of Resident #40 has had a hole in the wall for a couple months because he was waiting on approval from the corporation to order the dry wall. He stated he got the dry wall two weeks ago but had not fixed it yet.

Review of the undated facility policy titled, Resident Environmental Quality:, revealed it was the policy of the facility to be designed constructed, equipped, and maintained to provide a safe functional, sanitary and comfortable environmental for residents, staff and the public.

Based on observation, review of the medical record and interview with staff, the facility failed to ensure Resident #31 was properly assessed to ensure the resident was free from physical restraint. This affected one resident (Resident #31) of one reviewed for physical restraints.

Findings include:

Review of the medical record revealed Resident #31 was admitted to the facility on 07/05/19. Diagnoses included Alzheimer's disease, anorexia, fatigue, dementia, repeated falls, hypertension and COVID-19.

Review of the plan of care dated 07/09/19 revealed Resident #31 was at risk for fall related injury and falls related to weakness, dementia, history of falls, impaired mobility, chooses not to use a walker, incontinence of bowel and bladder, impaired range of motion to the right shoulder. Interventions included to be up in the Broda chair with self releasing seatbelt when not in wheelchair and self release seatbelt in applied in the wheelchair.

Review of the Annual Minimum Data Set assessment dated 03/08/23 revealed Resident #31 had severely impaired cognition. She required extensive assistance of one staff member for bed mobility, dressing, toilet use and personal hygiene.

Review of the physical device and restraint assessment dated 03/08/23 revealed Resident #31 had a lap belt that served as a reminder to call for assistance before standing up. The assessment did not identify the device as a restraint because the resident was able to remove the device, therefore did not identify the medical/environmental conditions prompting the use of restraint, alternatives attempted, considerations for the use of a restraint, recommendations for the use of the restraint, determination, and consent to use the restraint.

Review of the Fall risk assessment dated 03/17/23 revealed Resident #31 was a risk for falling.

Review of the physician's orders revealed Resident #31 had an order for a self releasing seatbelt (SRSB) to the wheelchair and Broda chair dated 04/06/23.

Observations on 04/24/23 at 9:13 A.M. and 10:25 A.M. revealed Resident #31 was up in the Broda chair with a SRSB. Further observation with Registered Nurse (RN) #826 on 04/24/23 at 10:25 A.M. revealed Resident #31 was able to release the Velcro part of the seatbelt; however she was unable to remove it from the loop to completely remove it. An interview at this time RN #826 verified Resident #31 had not completely removed the SRSB herself and she was unable to understand how to release the belt completely.

Based on observation, medical record review, shower sheet review, and interview, the facility failed to ensure Resident #36 who was dependent on staff assistance for activities of daily living (ADL) was shaved per his preference. This affected one resident (Resident #36) of two resident reviewed for (ADL).

Findings included:

Review of the medical record revealed Resident #36 was admitted to the facility on 12/11/20. Diagnoses included Guillain-Barre syndrome, neuromuscular dysfunction of the bladder, cerebral infarction, vitamin B12 deficiency, anemia, seizures, mild cognitive impairment, hypertension, and weakness.

Review of the quarterly Minimum Data set assessment dated 01/30/23 revealed Resident #36 had moderately impaired cognition. He required extensive assistance of one staff member for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene.

Review of the progress notes from 02/24/23 through 04/25/23 revealed no documentation Resident #36 refused to be shaved.

Review of the shower schedule revealed Resident #36 received his showers on Tuesdays and Fridays.

Review of the Bathing Task section in Point Click Care revealed Resident #36 had a shower on 04/14/23, 04/21/23 and 04/25/23.

Review of the shower sheets from 04/04/23 to 04/25/23 revealed no documentation of Resident #36 being shaved.

On 04/26/23 at 11:05 A.M. an interview with Resident #36 revealed he had not been shaved in over a week. He stated he did not like to have a beard.

On 04/26/23 at 1:20 P.M. an interview with State Tested Nursing Assistant #846 revealed the male residents were to be shaved on their shower days. She stated the residents received two showers a week. She stated they would document if they trimmed their nails or shaved them on the shower sheets. She sated Resident #36 had never refused to be shaved for her. At 1:22 P. M. she verified Resident #36 needed shaved. She asked him if he wanted shaved and he said yes.

Review of the undated facility policy titled, Grooming a Resident's Facial Hair

Based on observation, record review and interview, the facility failed to ensure care planned interventions were in place to prevent Resident #30 from developing a pressure ulcer, and failed to ensure the pressure ulcer was comprehensively assessed, properly treated, and interventions were initiated to promote healing.

Actual harm occurred on 09/15/22 when Resident #30 who was cognitively impaired, at risk for pressure ulcer development, and required extensive assistance of staff for bed mobility, was found to have a pressure ulcer to the left heel that was first assessed to be a Stage III (full thickness skin break into subcutaneous tissue but does not go into the muscle and bone) ulcer which deteriorated to an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) without proper assessment, treatment, and interventions implemented. This affected one resident (Resident #30) of two residents reviewed for pressure ulcers.

Findings included:

Resident #30 was admitted to the facility on 07/30/20 with diagnoses including Alzheimer's disease, diabetes, chronic obstructive pulmonary disease, diabetes neuropathy, peripheral vascular disease, chronic kidney disease, hyperlipidemia, anemia, anxiety disorder, epilepsy, bipolar disorder, major depressive disorder, schizoaffective disorder, insomnia, dementia, cataracts, hypertensive retinopathy, and intellectual disabilities.

Review of the plan of care initiated on 07/30/20 revealed Resident #30 was at risk for impaired skin integrity/pressure injury related to having a communication deficit, impaired mobility, muscle weakness, amputated right great toe, peripheral vascular disease, poor safety awareness, and required staff interventions with bed mobility and transfers. Interventions included to conduct weekly head to toe assessments, document and report abnormal findings, encourage to float heels while in bed, follow facility policies for the prevention and treatment of impaired skin, observe finger and toenails to see of they need trimmed, observe for sliding down in chair and reposition, observe skin with care and showers, pressure reduction cushion to wheelchair, pressure reduction mattress to the bed, and provide incontinence care with each incontinent episode. The plan of care had a revision date of 11/01/22, but new interventions were not added on this date.

Review of the Braden Scale dated 07/02/22 revealed Resident #30 was at risk for developing pressure ulcers.

Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated 07/07/22 revealed Resident#30 required extensive assistance of two staff for bed mobility. The assessment did not reflect the presence of any type of pressure ulcers.

Review of Resident #30's medical record from 07/30/20 through 09/15/22 revealed no documented evidence the resident's heels were floated (as noted as a care plan intervention).

Review of Resident #30's therapy note dated 09/15/22 at 1:14 P.M. revealed during dressing the therapist was putting on Resident #30's left sock and noticed a change in the skin condition to his left heel.

Review of the nurse's note dated 09/15/22 at 4:40 P.M. revealed per therapy Resident #30 had a half dollar size pressure area to the left heel. The nurse practitioner was notified and gave orders to consult Pinnacle Wound Care and a foam dressing to the site.

Review of the physician's orders for Resident #30 revealed an order, dated 09/15/22 to consult Pinnacle Wound Care for a pressure area to the left heel and apply foam dressing to the area until seen. The medical record lacked evidence the left heel was comprehensively assessed to include measurements, description, and staging of the wound at that time.

Review of the Weekly Wound Evaluation dated 09/21/22 revealed Resident #30 had an in house Stage III pressure ulcer to his left heel. The wound measured 2.8 centimeters (cm) in length by 3.3 cm in width by 0.1 cm by 0.1 cm in depth. The wound was 25 percent dark purple and 75 percent granulation (healthy tissue).

Review of the Wound Care note dated 09/21/22 revealed Resident #30 had a Stage III pressure ulcer to his left heel. The wound measured 2.8 centimeters (cm) in length by 3.3 cm in width by 0.1 cm by 0.1 cm in depth. The wound was 25 percent dark purple and 75 percent granulation. No current treatment was in place. New orders to cleanse the left heel ulcer with normal saline, apply adaptic, cover with a abdominal dressing and wrap with Kerlix daily.

Review of the September 2022 Treatment Administration Record (TAR) revealed no documentation of a treatment being completed to the left heel of Resident #30 until 09/22/22.

Review of the physician's orders for Resident #30 revealed an order dated 09/22/22 to cleanse the left heel ulcer with normal saline, apply adaptic, cover with a abdominal dressing and wrap with Kerlix daily.

Review of Resident #30's medical record from 09/15/22 through 09/28/22 revealed no evidence additional pressure ulcer interventions to assist the pressure ulcer in healing and from deteriorating were implemented, including floating the resident's heels.

Review of the Weekly Wound Evacuation dated 09/28/22 revealed Resident #30 had an in house unstageable pressure ulcer (the base of the wound cannot be visualized as to what type of anatomical tissue was involved) to his left heel. The wound measured 3.2 cm in length by 3.2 cm in width by 0.1 cm deep with a moderate amount of serosanguinous drainage. The wound was 50 percent slough (dead tissue) and 50 percent granulation. The wound was worsening. New treatment order implemented for silver alginate, abdominal dressing and wrap with Kerlix. In addition, new orders were obtained for a low air loss mattress, protein supplements twice daily and Prafo (pressure relieving) boot when up in the wheelchair.

Review of the Wound Care note dated 09/28/22 revealed Resident #30 had a pressure ulcer to his left heel that was a Stage III but now was unstageable. The wound measured 3.2 cm in length by 3.2 cm in width by 0.1 cm deep with a moderate amount of serosanguinous drainage. The wound was 50 percent slough and 50 percent granulation. The wound was worsening.

Review of the physician's orders for Resident #30 revealed an order, dated 09/29/22 for a low air loss mattress and Prafo boots while up in the wheelchair.

Review of the plan of care initiated on 11/24/22 revealed Resident #30 had a Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) pressure ulcer to the left heel. Interventions included to administer medication as ordered, administer treatments as ordered, assess/record/monitor wound healing. measure the length, width, and depth where possible, assess and document status of the wound perimeter, wound bed and healing, report and improvements and declines to the physician's, and avoid positioning the resident left heel on the bed and float heels as needed.

Review of the quarterly Minimum Data Set 3.0 assessment dated 03/17/23 revealed Resident #30 had moderately impaired cognition. He required extensive assistance of two staff members for bed mobility and had an in house Stage III pressure wound.

Review of the physician's orders for Resident #30 revealed an order, dated 04/12/23 to encourage resident to use a foot boot to left lower extremity while up as tolerated to protect the left heel.

Observation on 04/25/23 at 10:10 A.M. of Licensed Practical Nurse (LPN) #841 providing wound care to Resident #30 revealed the resident's left heel wound was nickel-size with a dark pink non-blanchable wound bed with dried peeling skin surrounding the wound. There was no drainage or odor noted to the wound.

Observation on 04/25/23 at 3:10 P.M. revealed Resident #30 was up in the wheelchair in the hallway by nurse's station. The resident did not have his foot boot on his left foot as ordered.

On 04/25/23 at 3:12 P.M. interview with LPN #841 revealed she did not see an order for Resident #30's foot boot. The LPN then checked the orders and verified there was an order for the resident to have his foot boot while up in the chair.

Observation on 04/26/23 at 1:25 P.M. revealed Resident #30 was sitting in the hallway. The resident did not have his foot boot on his left foot. An interview at this time with Registered Nurse (RN) #836 verified the resident did not have his foot boot on his left foot.

On 04/26/23 at 10:56 A.M. interview with RN #836 revealed she had just starting doing wound care in January 2023 and prior to that wound care was done by Pinnacle Wound Care, however this provider no longer came to the facility. She stated when a wound was found, the floor nurses were able to assess and grid the wound. She stated she would then look at the wound as soon as she was able, usually the next day she worked. RN #835 verified there was no pressure ulcer injury assessment, measurement, staging or treatment in place for Resident #30 from 09/15/22 to 09/21/22 and no pressure ulcer injury interventions in place from 09/15/22 to 09/28/22. She verified the wound had been assessed to deteriorate following the initial development.

On 04/26/23 at 2:55 P.M. interview with RN #836 verified there was no documentation of staff floating Resident #30's heels prior to the left heel pressure ulcer developing or after the injury was identified from 09/15/22 to 09/28/22.

On 04/26/23 at 3:00 P.M. interview with LPN #840 revealed Pinnacle Wound did not want the facility to stage any wounds and she verified it had taken staff from Pinnacle Wound Care seven days to come into the facility to assess Resident #30's left heel wound, as they only came to the facility on Wednesdays. She verified Resident #30's left heel was not thoroughly assessed until 09/21/22 and confirmed pressure ulcer interventions were not put in place until 09/28/22. LPN #840 stated they implement pressure ulcer interventions when they stage the wound and they did not know the stage of the wound until Pinnacle Wound care assessed the wound. She verified Resident #30's wound had deteriorated after it developed.

Based on observation, interview, and record review, the facility failed to ensure safe discarding of cigarettes, and failed to ensure Resident #40 had his physician ordered soft helmet while up in the wheelchair. This finding had the potential to affect seventeen residents (Residents #5, #6, #11, #12, #13, #15, #16, #17, #19, #21, #26, #27, #28, #34, #45, #46 and #47) the facility identified as smokers, and one resident ( Resident #40) of four reviewed for accidents.

Findings include:

1. Observation on 04/24/23 at 4:05 P.M. with Activity Director #802 revealed the smoking patio had greater than thirty cigarette butts on the cement portion of the patio and cigarette butts lying in the rocks surrounding the cement patio. A fire proof receptacle was located on the patio and two fire proof ash trays were located on the tables on the patio.

Interview on 04/24/23 at 4:10 P.M. with Activity Director #802 confirmed the patio had a large amount of cigarette butts lying on the grounds. She stated the facility was educating the residents to use the fire proof receptacles to extinguish their smoking material.

The facility identified Residents #5, #6, #11, #12, #13, #15, #16, #17, #19, #21, #26, #27, #28, #34, #45, #46 and #47 as smokers.

Review of the facility smoking policy updated 03/25/22 indicated ashtrays made of non-combustible materials and safe design, and metal containers with self-closing covers into which the ashtrays can be emptied, shall be provided in all designated smoking areas.

2. Review of the medical record revealed Resident #40 was admitted to the facility on 09/01/21. Diagnoses include cerebral infarction, hemiplegia of the left side, acute respiratory failure, intracerebral hemorrhage, schizoaffective disorder, cannabis use, cocaine abuse, viral hepatitis C, viral hepatitis B, malignant neoplasm prostate, major depressive disorder, hypertensive urgency, anxiety disorder, hypertension, and COVID-19.

Review of the quarterly Minimum Data Set assessment dated 02/21/23 revealed Resident # 0 had moderately impaired cognition and required extensive assistance for activity of daily living.

Review of the April 2023 physician's orders dated 03/07/23 revealed Resident #40 had an order for a soft-shell helmet on at all times when out of bed.

Observation on 04/25/23 at 11:40 A.M., 3:07 P.M. and 4:00 P.M. revealed Resident #40 was up in the wheelchair without his soft helmet on his head.

On 04/25/23 at 4:00 P.M. an interview with Licensed Practical Nurse # 841 verified Resident #40 did not have his soft helmet on and he should have it on while he was up in the wheelchair.

On 04/27/23 at 9:30 A.M. an interview with Registered Nurse #836 revealed Resident #40 had to wear a soft helmet for head protection due to a brain injury.

Based on observation, record review and interview, the facility failed to ensure a medication error rate of less than 5% (percent). A total of 28 medications were administered with four errors for a medication error rate of 14.29%. The finding affected four (Residents #11, #25, #43, and #47) of four residents observed for medication administration.

Findings include:

1. Review of Resident #47's medical record revealed she was admitted on 08/16/22 with type two diabetes, muscle weakness and depression.

Review of Resident #47's physician orders revealed an order dated 02/23/23 for Lispro (fast acting insulin) inject 18 units subcutaneously (SQ) before meals for diabetes.

Observation on 04/24/23 at 4:44 P.M. with Registered Nurse (RN) #826 of Resident #47's morning medication administration revealed she checked the resident's blood sugar using a glucometer blood sugar machine with a result of 144. She then administered the Lispro fast acting insulin to the resident. Further observation revealed the resident was in bed and her meal tray was against the wall with 70% of the meal consumed. An interview with the resident at the time of the observation revealed she had consumed all of the meal that she wanted.

Interview on 04/24/23 at 4:50 P.M. with RN #826 confirmed Resident #47's insulin should have been administered prior to the meal but she was completing other tasks related to her job and was unable to administer the insulin in a timely manner.

2. Review of Resident #25's medical record revealed she was admitted on 04/25/22 with diagnoses including fibromyalgia, repeated falls and major depressive disorder.

Review of Resident #25's physician orders revealed an order dated 07/14/22 for vitamin D3 give 125 micrograms (mcg) by mouth one time a day for vitamin D deficiency.

Observation on 04/25/23 at 7:42 A.M. with Licensed Practical Nurse (LPN) #841 revealed she administered nine medications including vitamin D3 25 mcg.

Interview on 04/25/23 at 8:34 A.M. with LPN #841 confirmed she administered vitamin D3 25 mcg and the order was for vitamin D3 125 mcg. She indicated she administered the wrong dose in error.

3. Review of Resident #11's medical record revealed he was admitted on 11/19/18 with diagnoses including cerebral infarction, heart failure and essential hypertension.

Review of Resident #11's physician orders revealed an order dated 04/05/22 to administer Atenolol 25 milligrams (mg) one tablet one time a day for hypertension and hold if the systolic blood pressure was less than 100 or the heart rate was less than 60.

Observation on 04/26/23 at 7:21 A.M. with LPN #843 revealed he administered eight medications to Resident #11 including the Atenolol blood pressure medication. He was not observed to take the resident's blood pressure or pulse prior to administering the medications including the Atenolol blood pressure medication.

Interview on 04/26/23 at 7:26 A.M. with LPN #843 confirmed he did not obtain Resident #11's blood pressure or pulse prior to administering the Atenolol blood pressure medication as indicated in the physician's order.

4. Review of Resident #43's medical record revealed he was admitted on 01/24/23 with diagnoses including bipolar disorder, essential hypertension and muscle weakness.

Review of Resident #43's physician orders revealed an order dated 04/16/23 for Magnesium oral tablet give 400 mg by mouth three times a day for a supplement.

Observation on 04/26/23 at 7:29 A.M. with LPN #843 of Resident #43's medication administration revealed nine medications were administered including Magnesium 84 mg and the dose should have been 400 mg.

Interview on 04/26/23 at 7:33 A.M. with LPN #843 confirmed Resident #43 was administered the wrong dose of magnesium.

A total of 28 medications were administered with four errors for a medication error rate of 14.29%.

Review of the Medication Administration policy revised 11/17 indicated medications were administered by licensed nurses, or other staff who were legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

Based on observation, review of the medical record and interview, the facility failed to ensure the Resident #40 had physician ordered adaptive devices to assist with meals. This affected one resident (Resident #40) of three reviewed for nutrition.

Finding include:

Review of the medical record revealed Resident #40 was admitted to the facility on 09/01/21. Diagnoses include cerebral infarction, hemiplegia of the left side, acute respiratory failure, intracerebral hemorrhage, schizoaffective disorder, cannabis use, cocaine abuse, viral hepatitis C, viral hepatitis B, malignant neoplasm prostate, major depressive disorder, hypertensive urgency, anxiety disorder, hypertension, and COVID-19.

Review of the quarterly Minimum Data Set assessment dated 02/21/23 revealed Resident #40 had moderately impaired cognition and required extensive assistance for activity of daily living.

Review of the physician orders revealed Resident #40 had an order for a regular diet, double entrees, sectioned plate and handled cup dated 03/12/23.

Observation on 04/26/23 at 9:00 A.M. revealed Resident #40 was in bed with his breakfast tray in front of him on the over the bed table, his meal ticket indicated he was to have a handled cup; however he had one large Styrofoam cup and one regular eight ounces glass on his tray.

On 4/26/23 at 9:03 A.M. an interview with Licensed Practical Nurse #841 verified Resident #40 did not receive a handled cup with his meal.

2. On 04/24/23 at 10:35 A.M. an interview with Resident #37 revealed he was told he had to remove all the food out of the facility refrigerator and use the resident refrigerator on the second floor a crossed from room 231. He stated it was dirty, smelled and had bowls of food in it with mold in them, a piece of sausage just laid inside it and it had bugs in it.

Observation on 04/24/23 at 10:45 A.M. of the second floor refrigerator revealed it had a strong smell of rotten food. There were two Styrofoam to go boxes not dated, a container of macaroni salad with no date that had mold on it, three bowls of unidentifiable substance with no dated that had mold on them, a piece of breakfast sausage was just lying on the top shelf, and a plate with an unidentifiable substance on it, and the bottom of the refrigerator had numerous little black bugs.

Interview on 04/24/23 at 10:50 A.M. with Registered Nurse #836 verified the refrigerator on the second floor a crossed from room 231 smelled, was dirty inside and had small black bugs in it

Observation on 04/25/23 at 4:05 P.M. revealed the refrigerator on the second floor a crossed from room 231 still had not been cleaned out. An interview at this time State Tested Nursing Assistant #846 verified the refrigerator had not been cleaned out yet.

Based on observation, interview, and record review, the facility failed to ensure trash was properly contained on the facility grounds. This had the potential to affect all 47 residents currently residing in the building.

Findings include:

An observation with the Administrator on 04/26/23 at 9:23 A.M. of the grounds around the parking lot and fence line revealed styrofoam cups, used surgical masks, water bottles, empty beer cases, and stray socks. The Administrator explained there were tarps down along the fence line to smother the weeds so they can lay mulch down, but he did confirm there was a lot of refuse along the fence.

An interview on 04/26/23 at 9:23 A.M. with the Administrator verified the facility did not contain their garbage around the facility grounds.

Review of the facility policy titled Disposal of Garbage and Refuse