Clovernook Health Care and Rehabilitation Center

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to follow the physician's order for a resident's pressure ulcer treatment. This affected one (Resident #65) of three residents reviewed for pressure ulcers. The facility census was 106.

Findings include:

Review of the medical record revealed Resident #65 was admitted on 05/24/24. Diagnoses included surgical amputation, cognitive communication deficit, acquired absence of below the knee, type two diabetes mellitus, end stage renal disease, dependent on renal dialysis, and chronic pulmonary disease.

Review of the Minimum Data Set (MDS) assessment dated 05/24/24 revealed Resident #65 was cognitively impaired. Resident #65 was dependent on staff for transfers, toileting, bathing, and personal hygiene.

Review of the plan of care dated 05/28/24 revealed Resident #65 had pressure ulcer and had potential for pressure ulcer development related to immobility, incontinence, and disease process. Resident #65 was admitted on 05/24/24 with stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed.) to sacrum. Interventions included to administer medication as ordered, administer treatments as ordered, and follow policies and protocols for the preventions and treatment of skin breakdown.

Review of the physician order dated 06/18/24 for Resident #65 revealed an order to cleanse sacrum with derma cleanse, apply triad paste, and leave open to air every shift.

Observations on 06/24/24 from 12:07 P.M. through 12:25 P.M. revealed State Tested Nursing Aide (STNA) #239, and License Practical Nurse (LPN) #229 were assisting in incontinence care for Resident #65. Resident #65 had a dressing on his coccyx that was covered with feces. LPN #229 took off old dressing off and threw it away. STNA #239 had asked LPN #204 to come in Resident #65's room while receiving incontinence care. LPN #204 who was Resident #65's nurse for the day, had directed LPN #229 to perform the treatment on Resident #65's coccyx. LPN #204 directed LPN #229 to cleanse the coccyx area, then apply triad and leave open to air. LPN #204 handed STNA #239 the wound treatment supplies. STNA #239 then cleansed Resident #65 coccyx with wash cloth with soap and water. STNA #239 then patted dry the coccyx with a dry towel. LPN #229 took a dressing and applied triad on dressing and applied directly to Resident #65's coccyx.

Interview on 06/24/24 at 12:45 P.M. with STNA #239 confirmed that she did wash Resident #65's coccyx with a washcloth and soap and water only.

Interview on 06/24/24 at 12:50 P.M. with LPN #229 verified Resident #65's treatment was to use derma cleanse, then apply Triad, and leave open to air.

Interview on 06/24/24 at 12:55 P.M. with LPN #204 confirmed she did tell LPN #229 the incorrect way to perform Resident #65's coccyx treatment. LPN #229 stated she should have used the Derma Cleanser during wound treatment.

Review of the facility policy titled Wound Care

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.

Based on record review, observation, staff interviews, interview with the Medical Director (MD), review of hospital records, review of facility investigation, review of witness statements, review of personnel records, review of Hoyer Lift Manufacturer Guidelines, and review of facility policy, the facility failed to ensure a resident was safely transferred by a Hoyer mechanical lift. This resulted in Actual Harm on 12/19/23 when Resident #15 was being transferred from the wheelchair to the bed with the use of a mechanical lift by former State Tested Nursing Assistant (STNA) #30 and STNA #30 hit the resident's right leg on the mechanical lift support bar. Resident #15 complained of right leg pain, was seen by the facility's Nurse Practitioner (NP) who ordered an Xray which resulted in Resident #15 being diagnosed with a right distal femoral fracture. Subsequently, Resident #15 was sent to the local hospital on 12/21/23 where he was diagnosed with a right distal femoral fracture, underwent a surgical repair of the fracture, and admitted to the hospital for five days. This affected one resident (#15) of the four residents reviewed for accident hazards. The facility census was 111.

Findings include:

Review of the medical record for Resident #15 revealed an admission date of 06/30/23 and discharged to the hospital on 05/08/24. Diagnoses included cirrhosis, anxiety, chronic respiratory failure, morbid obesity, depression, diabetes, osteoarthritis, and chronic pain.

Review of the care plan dated 07/19/23 for Resident #15, revealed the resident was dependent on two staff members using a Hoyer lift for all transfers.

Review of a Nurse Practitioner progress note dated 12/20/23 for Resident #15 and authored by NP #40, revealed the resident was seen for ongoing management of his medical conditions to include weakness. The assessment noted no new concerns or changes per Resident #15 and per the staff. Resident #15 had elevated ammonia levels of 186 (normal 15 to 45) and the resident had been refusing his lactulose (medication to decrease the intestinal production and absorption of ammonia). Resident #15 complained of pain in his left knee and an Xray was ordered. The note did not mention NP #40 had been informed of a fall or an incident involving a Hoyer lift and Resident #15.

Review of the Interdisciplinary Team (IDT) Post Fall/Incident Investigation/Summary dated 12/20/23, revealed Resident #15 reported to Unit Manager (UM) #80 that he had a fall on 12/19/23 during the night shift (7:00 P.M. to 7:00 A.M.) and a male staff member (identified as former STNA #30) got the resident up and the resident was complaining of right knee pain. Resident #15's assessment revealed there was no swelling, redness, or injuries noted. The vital signs were as follows: blood pressure (BP) 114/61 millimeters of mercury (mm/Hg), pulse 88 beats per minute, respirations 17 breaths per minute, temperature 97.2 degrees Fahrenheit (F), pulse oximetry 96 percent (%) on two-liters per minute (LPM) of oxygen per nasal cannula (NC). NP #40 was in the facility and examined Resident #15 with new orders to obtain an Xray of the resident's right knee. The root cause analysis (RCA) of the incident revealed STNA #30 failed to follow the company policy when utilizing a Hoyer mechanical lift. Interventions included terminating STNA #30, and a therapy evaluation and treatment were ordered for Resident #15. The follow-up to the investigation revealed the resident did not fall but the resident's leg and side of abdomen was hanging out of bed and the resident was transferred back to the bed improperly.

Review of STNA #70's statement revealed on 12/20/23 he received a shift report from the two-night shift aides. Resident #15 had his call light on, so STNA #70 went to answer it and Resident #15 indicated he needed to be cleaned up. STNA #70 started to change the resident when he was yelling and crying saying he fell last night and his knee hurt. STNA #70 went to get another STNA to assist him when Resident #15 was yelling and crying so he told the nurse.

Review of Xray results dated 12/21/23 for Resident #15 revealed the resident had a complete oblique fracture involving the distal third of the right femur with anterior lateral displacement of the distal fracture.

Review of a Social Services progress note dated 12/21/23 at 4:37 P.M. for Resident #15, revealed the resident's Xray results were received and they were communicated to MD #35 who ordered the resident to be sent to the hospital due to a fracture of his right femur. Resident #15 was alert and oriented at time of departure with EMS.

Review of the hospital records dated 12/21/23 for Resident #15, revealed the resident presented to the Emergency Room (ER) with a fall at the nursing home two days ago and then diagnosed with a hip fracture. The resident reported he fell out of the bed and his right leg went underneath him and he was having right hip pain. The resident had continued to complain of pain since the fall and was found to have a right femoral fracture at the nursing home. Another Xray was completed which showed the resident had a comminuted distal right femoral fracture redemonstrated with mild displacement/rotation at the fracture site, with extensive surrounding soft tissue swelling. An Orthopedic surgeon was consulted and the resident required an open reduction internal fixation (ORIF) with intramedullary nailing (a surgical procedure to repair the fracture) surgical procedure. The notes indicated the resident went into respiratory failure post-surgery and was transferred to the intensive care unit (ICU) for continued treatment. Resident #15 was discharged back to the facility on 12/26/23.

Review of STNA #76's undated witness statement revealed he worked on 12/19/23 from 7:00 P.M. to 7:00 A.M. (night shift) and upon coming in to work, Resident #15 was screaming, crying, throwing things at employees, and wanted to go to bed. STNA #76 transferred the resident to bed. STNA #76 reported he worked again on 12/20/23 (7:00 P.M. to 7:00 A.M.) and was questioned if Resident #15 fell out of bed on 12/19/23. STNA #76 reported the resident did not fall but STNA #30 had indicated Resident #15 was slipping out of bed, when he and STNA #30 had pushed him back in the bed.

Review of LPN #45's undated witness statement revealed she worked on 12/19/23 from 7:00 P.M. to 7:00 A.M. and when she arrived for her shift, Resident #15 was at the nurse's station trying to call his family; however, the number was no longer working and Resident #15 became very upset and started yelling, crying, screaming, and throwing things at the staff. LPN #45 tried to call the number again and the number was no longer in service. Resident #15 started yelling at the staff again. Resident #15 eventually calmed down and was placed in bed by the STNAs. LPN #45 was doing her medication administration, when she observed Resident #15 wrapped in a top sheet with his left leg out of the bed with his bottom close to the edge of the bed. LPN #45 went and got former STNA #30, and they adjusted the resident back in the bed by the bottom pad. Resident #15 was yelling that he wanted to call his family. LPN #45 reminded Resident #15 that they tried two times already and the number did not work.

Review of former STNA #30's verbal statement via telephone dated 12/21/23 and authored by the DON, revealed when former STNA #30 came on shift on 12/19/23 at 7:00 P.M., Resident #15 was yelling and throwing items at him and the staff because he wanted to go to the bed. Former STNA #30 reported he and LPN #45 transferred the resident into the Hoyer lift and while Resident #15 was up in the air, STNA #30 had to swing the resident around the Hoyer pole to position him in the bed. Resident #15 started screaming my legs. Former STNA #30 reported he proceeded to move the resident's legs around the Hoyer pole, and he did not notice anything different about Resident #15's right leg until he performed care for him. Former STNA #30 stated Resident #15 was unable to move his right leg like normal, and STNA #30 reported this to LPN #45. The DON noted she contacted LPN #45 and she indicated she did not assist former STNA #30 with the Hoyer transfer and nothing about Resident #15's leg was reported to her. The DON noted she contacted former STNA #30 again and he retracted his statement and admitted he transferred Resident #15 by a Hoyer lift by himself. Former STNA #30 stated Resident #15 did not fall and the only time Resident #15 made mention of his leg was when the resident was being moved around the Hoyer pole. Former STNA #30 reported LPN #45 came out of the resident's room and asked him for assistance. When former STNA #30 entered the room, Resident #15's left leg was off the bed and his abdomen was slightly hanging off. STNA #30 reported he repositioned Resident #15 with a draw sheet while LPN #45 guided the resident's left leg and stomach back in the bed. Former STNA #30 stated Resident #15's right foot was wrapped in his blanket and the resident was yelling about wanting to use the phone while they repositioned him. Former STNA #30 was suspended pending an investigation by the DON.

Review of the Discharge Return Anticipated Minimum Data Set (MDS) assessment dated 04/24/24 revealed Resident #15 was cognitively impaired and was dependent on staff for activities of daily living (ADLSs).

Interview with the Administrator and Director of Nursing (DON) on 05/08/24 at approximately 4:00 P.M., revealed Resident #15 had an Xray completed on 12/21/23 which showed a fractured right femur. The facility started an investigation and learned of a Hoyer incident involving former STNA #30 and Resident #15 on 12/19/23. The DON stated former STNA #30 was immediately suspended pending the outcome of the investigation and was eventually terminated on 12/22/23 for failing to follow policy when transferring residents via Hoyer lift. The DON stated former STNA #30 had originally lied during his first interview by saying LPN #45 assisted him with transferring Resident #15 to the bed; however, when the DON questioned LPN #45 about the incident, LPN #45 denied helping STNA #30 with the Hoyer transfer. The DON reported she reinterviewed former STNA #30, and he admitted to transferring Resident #15 to the bed by himself and when he was swinging the resident's body towards the bed, Resident #15's leg hit the Hoyer bar and that was when Resident #15 started saying his knee hurts. Former STNA #30 stated he reported the incident to LPN #45; however, LPN #45 stated the incident was never reported to her and therefore nothing was documented about the incident.

A telephone interview with MD #35 on 05/13/24 at 12:30 P.M., revealed he was never informed of any fall or an incident involving Resident #15 on 12/19/23; however, NP #40 reported to him on 12/20/23, Resident #15 was complaining of left leg pain, and she ordered an x-ray. MD #35 stated Resident #15 was often non-compliant with his care and had behaviors. MD #35 stated he learned of the resident's femur fracture after the Xray was completed on 12/21/23.

A telephone interview with NP #40 on 05/13/24 at 2:32 P.M., revealed she was in the facility on 12/20/23 and saw Resident #15 due to him complaining of pain. Resident #15 complained of pain in his knee and hip, and she ordered an Xray. NP #40 could not recall which leg the resident complained about since she did not have his chart accessible. NP #40 reported she was never informed of the resident falling or an incident involving a Hoyer lift transfer. NP #40 also reported that Resident #15 is frequently confused especially when he refuses his lactulose, and his ammonia levels rise.

A telephone interview with former STNA #30 on 05/13/24 at 3:21 P.M., revealed when he went into work on 12/19/23 for the night shift (7:00 P.M. to 7:00 A.M.) he was assigned to care for Resident #15. The resident was in a wheelchair at the nurse's desk at the start of his shift yelling and saying he was going to throw himself on the floor. Former STNA #30 stated he used a Hoyer for bigger people without assistance and transferred Resident #15 to his bed. Former STNA #30 denied hitting Resident #15's leg, denied the resident falling and stated he did everything correctly and the resident was placed in the bed with no issues. Former STNA #30 stated approximately one and a half hours later, he noticed Resident #15 was on the floor on his bottom with his back against the bed. Former STNA #30 reported the fall to LPN #45. STNA #76 came in the resident's room to assist them putting Resident #15 back into the bed and he was told by LPN #45 not to say anything about Resident #15 falling from the bed. STNA #30 stated they picked up the resident's legs and pushed/pulled until they got him back into the bed.

A telephone interview with LPN #45 on 05/14/24 at 7:55 A.M., revealed when she came on shift on 12/19/23 at 7:00 P.M., Resident #15 was yelling, screaming, and throwing things, but this was a normal behavior. LPN #45 stated she asked Resident #15 how she could help, and he wanted to call his family, so LPN #45 assisted Resident #15 with making the phone call, but the number was not in service any longer. LPN #45 stated after helping Resident #15, she left the area to start her medication administration while former STNA #30 assisted Resident #15 to the bed. LPN #45 stated she was passing medications and was never asked by former STNA #30 to assist with the transfer. LPN #45 stated she was not aware that two staff members were required for Hoyer transfers. LPN #45 reported that while she was doing her rounds, she noticed Resident #15 was halfway off his bed with his left leg hanging off the bed. She got former STNA #30 to assist her with getting Resident #15 back in the bed and they pushed/pulled the resident until they got him back and positioned correctly in the bed. LPN #45 stated Resident #15 did not fall, he was only leaning off the bed. LPN #45 denied telling former STNA #30 not to report any fall because Resident #15 did not fall on 12/19/23. LPN #45 stated she could not remember if Resident #15 had any complaints of pain during the shift.

A telephone interview with STNA #76 on 05/14/24 at 11:40 A.M., revealed he did not assist in any transfers and was never asked to help get Resident #15 off the floor.

Review of the personnel file for former STNA #30 revealed a hire date of 12/07/22 with an active STNA certification, no former disciplinary actions, no coachable moments, no prior resident complaints, and he was terminated by telephone on 12/22/23 for failing to follow the company policy when utilizing a Hoyer lift.

Review of Hoyer Lift Manufacturer Guidelines revised on 06/14/23, revealed operators should watch the video, read the manual, complete a competency checklist and practice on fellow staff member before use with patients.

Review of the facility policy titled Lifting Machine, Using a Mechanical (dated 07/2017) revealed at least two staff members are needed to safely move a resident with a mechanical lift and document the transfer. Staff were to be trained and demonstrate competency using the specific machines or devices utilized in the facility.

As a result of the incident, the facility took the following actions to correct the deficient practice as of 12/26/23.

On 12/21/23, former STNA #30 was suspended pending investigation upon discovery of the incident and was terminated on 12/22/23.

On 12/21/23, Resident #15 was sent to hospital for evaluation and admitted for a fractured femur which required surgical interventions. Resident #15 was returned to the facility on 12/26/23.

On 12/21/23, all 27 residents who were dependent on staff for Hoyer transfers were assessed by Unit Manager/ Assistant Director of Nursing (ADON)/RN #80 with no concerns noted.

On 12/21/23, all 27 residents who were dependent on staff for Hoyer transfers had their care plans reviewed by MDS Coordinator/RN #81 with no concerns noted.

Beginning on 12/21/23, the DON/designee initiated staff competency check offs for STNAs. Any STNA that did not complete a competency check off due to vacations or being off work, did not work until a successful check off was completed. All competency check offs were completed on 12/26/23. Audits of the competency check offs were completed for 26 STNA's with no issues identified. Audit results were reviewed during an ad-hoc Quality Assurance Performance Improvement (QAPI) meeting on 12/26/23.

On 12/21/23, the DON/designee-initiated and completed education to 26 STNAs on reporting changes of condition to the charge nurse, including but not limited to pain and documenting pain.

On 12/21/23, the DON/designee-initiated and completed education to 26 STNAs on proper use of a mechanical lift, including but not limited to number of staff required when transferring a resident. During orientation all new STNA' s hired must complete a Hoyer lift transfer competency before working on the floor and before utilizing a mechanical lift.

On 12/21/23, the DON/designee completed pain assessments and interviewed all 27 residents to determine if residents had any unreported falls or incidents. No issues were identified.

On 12/22/23, the DON/designee reviewed the incident and the self-imposed plan of correction with the IDT. All were in agreement with the plan.

Beginning on 12/26/23, the DON/designee initiated audits for charting of five residents three times a week for four weeks, then monthly for two months to ensure any documentation of pain was reported to the charge nurse. Audit results were reviewed in QAPI on 01/29/24 and then again on 02/27/2024.

Beginning on 12/26/23, the DON/designee began Hoyer lift competency check offs audits five times weekly for four weeks, then monthly for two months. The audit results were reviewed by QAPI on 01/29/24 and then again on 02/27/24.

This deficiency represents non-compliance investigated with Complaint Number OH00152927.

Based on medical record review, staff interview, and facility policy review, the facility failed to promptly notify the resident representative when residents tested positive for COVID-19 and/or were exposed to COVID-19 and were placed under isolation precautions. This affected two (Residents #38 and #105) of three residents reviewed for notification of change. The census was 104.

Findings include:

1. Review of Resident #38's medical record revealed Resident #38 was admitted to the facility on 06/15/21. Resident #38's diagnoses included but were not limited to hemiplegia and hemiparesis, hydrocephalus, epilepsy, cognitive communication deficit, dysphagia, dementia, major depressive disorder, and adjustment disorder with anxiety.

Review of Resident #38's Minimum Data Set (MDS) assessment, dated 11/27/23, revealed Resident #38 had mild cognitive impairment.

Review of Resident #38's medical profile revealed Resident #38's wife was deemed guardian of person.

Review of Resident #38's medical record revealed no evidence Resident #38's wife was notified when Resident #38 was placed under isolation precautions on 12/01/23 due to having been exposed to COVID-19 by his roommate (Resident #105).

2. Review of Resident #105's medical record revealed Resident #105 was admitted to the facility on 08/22/22. Resident #105's diagnoses included but were not limited to bipolar disorder, hemiplegia and hemiparesis, unspecified intellectual disabilities, epilepsy, mood disorder, major depressive disorder, psychosis, moyamoya disease, and unspecified convulsions.

Review of Resident #105's MDS assessment, dated 11/29/23, revealed Resident #105 had significant cognitive impairment.

Review of Resident #105's medical profile revealed Resident #105 had a resident representative.

Review of Resident #105's progress notes revealed Resident #105 tested positive for COVID-19 on 12/01/23.

Review of Resident #105's medical record revealed no evidence Resident #105's resident representative was notified when Resident #105 tested positive for COVID-19 on 12/01/23 and was placed under isolation precautions.

Interviews with Licensed Practical Nurse (LPN) #102, LPN #103, and LPN #104 on 01/05/24 at 2:30 P.M. and 2:45 P.M. revealed when there is a change in a resident's condition, which includes being placed under isolation precautions or testing positive for COVID-19, they are to report this to the physician/nurse practitioner and to the resident/resident representative. They indicated the notification should be documented in the residents progress notes.

Interview with LPN #101 on 01/05/24 at 3:30 P.M. revealed Resident #38 was placed under isolation precautions on 12/01/23 due to being exposed to Resident #105, who had tested positive for COVID-19. LPN #101 further revealed Resident #105 was placed under isolation precautions on 12/01/23 when he tested positive for COVID-19. LPN #101 indicated she told Resident #38's family the morning after Resident #105's positive COVID-19 test, that he was in isolation due to being exposed. LPN #101 was under the impression that the previous night shift nurse had called Resident #38's wife and informed her that Resident #38 was in isolation however when Resident #38's wife arrived on 12/02/23 with their two children, she was unaware that Resident #38 was in isolation.

Interview with Regional Director #105 and the Administrator on 01/05/24 at 5:25 P.M. confirmed there was no evidence Resident #38's wife was notified when Resident #38 was placed into isolation due to having been exposed to Resident #105, who tested positive for COVID-19. Additionally, the interview confirmed there was no evidence Resident #105's resposible party was notified when Resident #105 tested positive for COVID-19 and was placed in isolation.

Review of the facility policy titled Change in a Resident's Condition or Status

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.

Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, review of facility policy, and interview, the facility failed to ensure medications were obtained from a source with a Terminal Distributor of Dangerous Drugs (TDDD) license (which allows a business entity to purchase, possess, and/or distribute dangerous drugs at a specific location) specific to the State of Ohio. This deficiency affected four of four Residents (#10, #62, #92, and #97) reviewed for medications administered by a contracted ancillary provider. This affected six current Residents (#5, #50, #57, #67, #74 and #77) and 13 discharged Residents (#84, #85, #87, #88, #89, #90, #91, #92, #93, #94, #95, #96 and #97). The census was 108.

Findings include:

1. Record review for Resident #10 revealed he was admitted to the facility on 07/23/23. His diagnoses included, osteomyelitis, paraplegia, candidiasis, anemia, and insomnia.

Review of the most recent Minimum Data Set (MDS) assessment for Resident #10, dated 08/28/23, revealed he was cognitively intact. Resident #10 required extensive assistance from staff with bed mobility, toileting, personal hygiene, and dressing. He was totally dependent on staff for transfers. Resident #10 required supervision from staff with eating.

Review of the plan of care dated 08/28/23 revealed the resident had potential for nutritional risk related to anemia, and infection.

Review of physician orders dated 07/25/23 revealed Infection and Derma infusion protocol for Dript intravenous (IV) Nurse-Dript IV therapy infusion one time 500 milliliters (ml) normal saline (0.9%) 500 ml/hour (hr), total additive volume, 31 ml. Additive formula: Ascorbic acid five gram (gm), B complex B five (Dexpanthenol) 250 mg, B seven Biotin 20 mg, Zinc 10 mg, Glutamine 150 mg, Arginine 500 mg, Ornithine 150 mg, Lysine 250 mg, Citrulline 250 mg, Glutathione 600 mg, three ml given intravenous push (IVP) at the end of infusion, one time only for micronutrient hydration therapy for one day one time only for hydration and nutritional wellness secondary to intake/chronic infection and frequent infections for one day infusion administration time may very based on clinic.

2. Review of the medical record for Resident #62 revealed an admission date of 03/22/23. Diagnoses included malnutrition, and paraplegia.

Review of the quarterly MDS Assessment dated 10/13/23 revealed Resident #62 had no impairments cognitive impairments. The resident was dependent for all care.

Review of the plan of care dated 10/13/23 revealed the resident had potential for nutritional risk related to malnutrition. Interventions included honor food/fluid preferences as possible and document food/fluid intakes.

Review of physician orders dated 08/21/23 revealed Infection/derma protocol-for Dript IV nurse-Dript IV therapy infusion one time (1,000 ml) 0.9% normal saline at 1,000 ml/hr. (Total additive volume, 24 ml). Additive formula: Ascorbic acid five mg, B complex B five(Dexpanthenol) 250 mg, Glutamine 150 mg, Citrulline 250 mg, and Zinc 10 mg.

3. Review of the medical record for Resident #92 revealed an admission date of 04/25/23. Diagnoses included high blood pressure, stroke, seizures, and pressure ulcer. The resident also received nutrition via a gastrostomy (g-tube) tube.

Review of the significant change MDS Assessment dated 08/23/23 revealed Resident #92 had impaired cognition. The resident was dependent for all care.

Review of the plan of care dated 08/23/23 revealed the resident had potential for nutritional risk related to inability to eat by mouth. Interventions included to provide and serve supplements as ordered.

Review of physician orders dated 09/21/23 revealed Nutrition Derma infusion protocol-Dript IV therapy infusion-one time 1,000 ml 0.9% normal saline at 500 ml/hr. (Total Additive volume 28.4 ml) B complex- B 1 Thiamine 200 mg, B two Riboflavin four mg, B three Niacin 200 mg, B five Dex 250 mg, Methylcobalamin two mg, Magnesium Chloride 1000 mg, Calcium Chloride 200 mg, Zinc 10 mg, glutamine 150 mg, Arginine 500 mg, Ornithine 150 mg, Lysine 250 mg, Citrulline 250 mg,

4. Review of the medical record for Resident #97 revealed an admission date of 04/05/23. Diagnoses included chronic respiratory failure, chronic lung disease, high blood pressure and seizures.

Review of the quarterly MDS Assessment dated 11/01/23 revealed Resident #97 had no cognitive impairments however he was dependent on staff for all care.

Review of the plan of care dated 11/01/23 revealed the resident had potential for nutritional risk related to recent falls and cognitive decline. Interventions included provide and serve supplements as ordered.

Review of physician orders dated 09/21/23 revealed Cognitive Infusion protocol-for Dript IV nurse-Dript IV therapy infusion-one time 500 ml. 0.9% normal saline at 500 ml/hr (total additive volume, 30.4 ml) Additive formula: ascorbic acid 5 mg, B Complex-B one Thiamine 200 mg, B two Riboflavin four mg, B three Niacin 200 mg, B five Dex 4 mg, B six Pyr four mg, glutamine 150 mg, Arginine 500 mg, ornithine 50 mg, Lysine 250 mg, Citrulline 250 mg, one time only for cognitive wellness.

Interview on 11/15/23 at 9:13 A.M. with Representative #405 for the ancillary provider stated they did not have State of Ohio TDDD licensure. He stated they were a Medical Entity, with a Medical Director licensed in the State of Ohio. Every other state in which they provided services did not require a special TDDD license and about three months of providing services in the Ohio area, they learned Ohio was an exception. He stated they applied for the license and were told they could continue providing services, license approval would take days. He stated an audit was conducted, and the Board of Pharmacy reported them. Simultaneously, the group had decided to stop providing services in Ohio unrelated to the licensure concerns. They rescinded their application for licensure. He stated they provided five specialized infusions that could be specialized based on resident needs. The intervention was created a couple of years ago and found to be beneficial for residents with chronic urinary tract infections (UTI), residents who did not eat or drink well, and/or weight loss concerns. He stated they presented the program to facility ownership.

Interview on 11/15/23 at 11:02 A.M. General Counsel #406 stated studies had shown hydration therapy improved and reduced risk of dehydration and re hospitalization. She stated she learned of this licensing concern on 11/14/23 and had contacted the General Counsel for the ancillary provider who reported when they started the process in Ohio they had been told they did not require TDDD license for Ohio. They reported they were initially told by the Board of Pharmacy they did not require an Ohio license, there were a ton of exemptions. They reported they applied for the license. General Counsel #406 stated the provider did not explain concerns with licensure when they announced they were no longer providing services. It was explained as a decrease in services related to rate freezes. She was not involved with the initial vetting process and could not provide specific information as to the steps involved in the approval. The corporation had started a compliance investigation on this with a compliance officer specific to this incident. At 12:25 P.M. General Counsel #406 revealed the contract had been signed on 12/09/22 by their Chief Financial Officer (CFO). The General Counsel at that time would have gone through a legal review with a multi-layered vetting process before it was presented to the CFO. She was in the process of investigating everything involved in the process and was still gathering information.

Interview on 12/12/23 at 9:13 A.M. with the Director of Nursing (DON) revealed the representative for the ancillary provider notified the facility either the last week of September or first week of October they would no longer provide the IV services. The DON confirmed six current Residents (#5, #50, #57, #67, #74 and #77) and 13 discharged Residents (#84, #85, #87, #88, #89, #90, #91, #92, #93, #94, #95, #96 and #97) received IV services by the ancillary provider.

Interview on 12/12/23 at 9:30 A.M. with the Administrator revealed she was unaware of adverse outcomes related to the infusion of the medications. She was not aware of concerns related to TDDD licensure and stated the initial service agreement would have been initiated at the corporate level before she was employed by the facility.

Review of the State of Ohio Terminal Distributor Licensure of Prescriber Practices https://www.pharmacy.ohio.gov/, dated 08/24/23, revealed a TDDD license allows a business entity to purchase, possess, and/or distribute dangerous drugs at specific locations. Terminal distributors of dangerous drugs include, but are not limited to, hospitals, pharmacies, Emergency Medical Services (EMS) organizations, laboratories, nursing homes, and prescriber practices. Distribution includes the administration of drugs on-site to patients as well as providing medications to patients to take away from the facility for later use. Dangerous drugs are defined in the Ohio Revised Code as any drug that meets any of the following: 1. Requires a subscription; 2. Bears on the label a Federal Legend (Rx Only or Caution: Federal law prohibits dispensing without a prescription); 3. Is intended for injection into the human body; or 4. Any drug that is a biological product as defined in section 3715.01 of the Revised Code. Ohio Revised Code (ORC) 4729.51 states that no licensed manufacturer, outsourcing facility, third-party logistics provider, repackage, or wholesale distributor shall sell dangerous drugs to anyone other than the following: (1) a licensed terminal distributor of dangerous drugs; (2) Any person exempt from licensure as a terminal distributor of dangerous drugs under section 4729.541 of the Revised Code (3) a licensed manufacturer, outsourcing facility, third-party logistics provider, repackage, or wholesale distributor; or (4) A terminal distributor, manufacturer, outsourcing facility, third-party logistics provider, repackage, or wholesale distributor that is located in another state, is not engaged in the sale of dangerous drugs within this state, and is actively licensed to engage in the sale of dangerous drugs by the state in which the distributor conducts business. In general, the exemptions to Ohio's TDDD licensure requirements do not apply if the prescriber practice is engaged in drug compounding. Compounding is defined as the preparation, mixing, assembling, packaging, and labeling of one or more drugs. Compounding includes the combining, admixing, diluting, reconstituting, or otherwise altering of a drug or bulk drug substance.

Review of facility policy titled, Governing Body

Based on record review and staff interview, the facility failed to complete a discharge summary of recapitulation of resident's stay. This affected one (#10) out of three residents reviewed for discharge rights. The facility census was 108.

Findings include:

Review of the closed medical record for Resident #10 revealed the resident was admitted on 09/14/23 and discharged home on 09/22/23. Diagnoses included osteoarthritis, diabetes mellitus, left knee replacement, intracerebral hemorrhage, and morbid obesity.

Review of the five-day Minimum Data Set (MDS) assessment 3.0 dated 09/21/23 for Resident #10, revealed the resident was cognitively intact and required supervision with activities of daily living (ADLs).

Review of the care plan dated 09/15/23 for Resident #10, revealed the resident was admitted in the facility for short term rehabilitation (rehab) and would have a safe discharge to the community after completing rehab with skilled nursing care and therapy.

Review of the medical record for Resident #10 with the Administrator and Director of Nursing (DON) revealed there was no documented evidence of a discharge recapitulation or summary completed for Resident #10 when the resident was discharged on 09/22/23.

An interview with the Administrator and the DON on 11/01/23 at 5:15 P.M., verified there was no documented evidence of a discharge recapitulation summary completed for Resident #10.

This deficiency represents non-compliance investigated under Complaint Number OH00147118.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.

Based on medical record review, interview, and policy review, the facility failed to check orders for as needed medications prior to administrating. This affected one (Resident #17) of six residents reviewed for medication administration. The in-house facility census was 102.

Findings include:

Medical record review revealed Resident #17 was admitted on 10/31/16 with diagnoses including anxiety disorder, depression, and vascular dementia.

Review of the care plan dated 10/31/16 revealed Resident #17 had the potential for altered mood status or psychosocial well-being related to depression, recent non-traumatic cerebral hemorrhage with left hemiparesis. Resident #17 was placed in nursing home due to history of stating he feels that he would be better off dead but has no intent of harming himself. Resident #17 stated again on 11/28/18 feelings of being better off dead with no thoughts of self-harm. He was seen by both counseling and psychiatry. Resident #17 no longer states thoughts of feeling better off dead, his mood has improved. On 07/06/19, Resident #17 stated he was having thoughts of being better off dead and thoughts of self-harm. Resident #17 denied having a plan, saying it would hurt. Resident #17 stated he hated the nursing home and still had fluctuations in his moods.

Review of the physician orders revealed an order dated 07/26/23 for alprazolam (anti-anxiety medication) 0.25 milligrams (mg), give one tablet every 24 hours as needed for anxiety related to other specified anxiety disorders for 14 days with the end date of 08/09/23.

Review of Resident #17's Individual Control Drug Record revealed alprazolam 0.25 mg was given five doses, after it was discontinued on 08/09/23, on the following dates: 08/09/23, 08/10/23, 08/11/23, 08/12/23, and 08/13/23.

Review of Licensed Practical Nurse (LPN) #87's statement dated 08/18/23 revealed she was completing the narcotic audit and noticed Resident #17 was receiving as needed narcotics when the order had been completed. LPN #87 alerted the Administrator since she was in the building that day.

Review of the Administrator's written statement dated 08/22/23 revealed an employee (LPN #69) was noted to have made a mediation error on Resident #17's as need alprazolam. When asked why she had administered the medication, LPN #69 stated Resident #17 requested it. Upon review of the medical record with LPN #69, she verified she administered Resident #17's as needed alprazolam after the order was completed. Until Administration informed LPN #69, she was unaware the order had been discontinued at any time. LPN #69 stated she did not look at the medication record before giving the medicine, she only looked at the narcotic sheet. LPN #69 stated it was a mistake on her part and she understood it was not good nursing practice. LPN #69 was educated on administration of medication, documentation of medication administration, administering pain medication, and controlled substances. LPN #69 was also given written counseling by the Administrator and Director of Nursing (DON).

Interview on 09/13/23 at approximately 12:15 P.M. with the Administrator revealed LPN #69 gave Resident #17 five doses of alprazolam 0.25 mg after it was discontinued.

Interview on 09/13/23 at approximately 12:30 P.M. with Resident #17 revealed he requested the as needed alprazolam every night. Resident #17 stated the medication helps him relax and helps with his anxiety.

A telephone interview on 09/19/23 at 9:45 A.M. with LPN #69 verified she administered Resident #17's alprazolam after it had been discontinued. LPN #69 verified if she would have reviewed the medical record, she would have known the medication was discontinued. LPN #69 stated she was educated after the mistake.

The deficiency was corrected on 08/23/23 after the facility implemented the following corrective actions:

LPN #69 was suspended and pending investigation on 08/18/23 by the DON.

The facility Nurse Practitioner was notified on 08/18/23 about Resident #17 receiving medications without proper orders.

The Regional Clinical Director (RCD) and DON reviewed narcotic sheets on the unit, 3-high, assignment on 08/18/23.

Unit manager (LPN #89) completed a full house as needed narcotic audit 08/21/23.

The RCD, Regional Director of Operations (RDO), Administrator, and DON reviewed narcotic sheets and medication administration records on 08/21/23.

LPN #69 met with the facility Administrator, RDO, and DON on 08/22/23 about the incident.

The DON in-serviced all licensed nurses on the following policies: Controlled Substances, Administering Medications, Documentation of Medication Administration, and Administering Pain Medications on 08/22/23.

The DON re-educated LPN #69 on the policies and procedures on Controlled Substances, Administering Medications, Documentation of Medication Administration, and Administering Pain Medications on 08/23/23.

The DON presented LPN #69 with a written corrective counseling on 08/23/23.

The DON interviewed Resident #17, which he stated he wants his as needed medication and had no ill effects receiving medication.

The DON will audit five residents prescribed as needed narcotics three times a week to ensure appropriate documentation of the as needed administration is noted on the MAR. This audit will be completed weekly for four weeks, then monthly for two months.

Corrective action will be initiated for any noted non-compliance.

Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring.

Review of the Administering Medications Policy (dated 04/2019) revealed the individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right route of administration before giving the medication.

This deficiency represents non-compliance investigated under Complaint Number OH00145706.

Based on observation, interview, and policy review, the facility failed to ensure medication carts and a medication room was locked. This had the potential to affect eight residents (#11, #12, #13, #14, #15, #16, #17, and #18) identified by the facility as independently mobile with confusion, The facility census was 102.

Findings include:

Observation on 09/13/23 at 5:49 A.M. of the second floor revealed the medication cart was unlocked with no staff present.

Interview on 09/13/23 at 5:51 A.M. State Tested Nursing Assistant (STNA) #67 reported the nurse was outside smoking.

Interview on 09/13/23 at 5:51 A.M. with Licensed Practical Nurse (LPN) #60 verified the second floor medication cart was unlocked and the nurse using the cart was outside smoking.

Observation on 09/13/23 at 5:54 A.M. revealed the medication cart on the first floor was unlocked with no staff around. Additionally, there was a large wad of paper stuck in the door of the medication room, keeping it unlocked.

Interview on 09/13/23 at 5:56 A.M. with LPN #21 verified the medication cart and medication room was left unlocked and unattended. LPN #21 reported the medication cart and room should have been locked.

Review of the Administering Medications Policy (dated 04/2019) revealed medication is kept closed and locked when out of sight of the medication nurse or aide.

Based on staff interview, Ombudsman interview, review of the facility policy, and record review, the facility failed to ensure residents were invited to care conferences and had the opportunity to participate in the development of their care plan. This affected two (#69 and #100) of three residents reviewed for resident care conference or participation in care planning. The facility census was 100.

Findings include:

1. Review of Resident #100's medical record revealed Resident #100 admitted to the facility on 06/09/23. Diagnoses included fracture of unspecified part of neck of left femur subsequent encounter for closed fracture with routine healing, end stage renal disease, dependence on renal dialysis, type two diabetes mellitus with hyperglycemia, protein calorie malnutrition, mood disorder due to known physiological condition with major depressive like episode, hypotension, repeated falls, hypertensive heart disease with heart failure, and congestive heart failure.

Review of the admission Minimum Data Set (MDS) assessment dated 06/16/23 revealed Resident #100 was severely cognitively impaired and required extensive assistance with bed mobility, dressing, toileting, and transfers. Resident #100 required limited assistance with personal hygiene and was independent with eating.

Review of Resident #100's care conference dated 07/27/23 revealed a care conference was held on 07/27/23 with Resident #100's daughter and Resident #100.

Interview with Ombudsman #700 on 08/10/23 at 12:48 P.M. revealed Resident #100 did not have care conferences upon admitting to the facility.

Interview on 08/15/23 at 11:43 A.M. with Social Services Designee (SSD) #11 verified Resident #100 did not have any care conferences from 06/09/23 to 07/26/23 despite Resident #100's comprehensive assessment being completed on 06/16/23.

2. Review of Resident #69's medical record revealed Resident #69 admitted to the facility on 04/26/21. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non dominate side, type two diabetes mellitus without complications, morbid obesity due to excess calories, muscle weakness, paroxysmal atrial fibrillation, hypertension, and weakness.

Review of the quarterly Minimum Data Set (MDS) assessment dated 07/03/23 revealed Resident #69 was cognitively intact and required extensive assistance with bed mobility, dressing, toileting, personal hygiene and transfers. Resident #69 required supervision with eating.

Review of Resident #69's care conferences from 12/05/23 to 08/10/23 revealed Resident #69 had a care conference on 12/05/23.

Interview with Resident #69 on 08/10/23 at 12:04 P.M. revealed Resident #69 had not been invited to any care conferences and had not had the opportunity to participate in the development of her care plan.

Interview on 08/15/23 at 11:43 A.M. with Social Services Designee (SSD) #11 verified Resident #69 did not have any conferences from 12/05/23 to 08/10/23.

Review of the facility's interdisciplinary team (IDT) care planning policy dated 10/10/22 revealed comprehensive person centered care plans are based on resident assessments and the IDT. The IDT includes but is not limited to the resident's attending physician, a registered nurse with responsibility for the resident, a nursing assistant with responsibility for the resident, a member of the food and nutritional service staff, the resident and the resident's representative and other staff as appropriate. Care plan meetings are scheduled at the best time of day for the resident and family when possible.

This deficiency represents non-compliance investigated under Complaint Number OH00145047 and OH00144843.

Based on record review, interview, and review of the resident handbook, the facility failed to ensure residents were treated with dignity. This affected one (Resident #14) of four residents reviewed for dignified care. The facility census was 110.

Findings include:

Review of the medical record for Resident #14 revealed an admission date of 03/24/23. Diagnoses included chronic diastolic heart failure, overactive bladder, unspecified epilepsy, unspecified uterovaginal prolapse, and generalized anxiety disorder.

Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated 05/16/23 revealed Resident #14 had moderately impaired cognition, had verbal and self-directed behaviors, did not reject care, and did not wander.

Review of the care plan dated 04/06/23 revealed Resident #14 was at risk for developing complications secondary to having bowel and bladder incontinence related to immobility. Interventions included to check every two hours and assist with toileting needs, to provide peri-care after each episode of incontinence, and to provide loose-fitting clothing.

Review of witness statements dated 07/15/23 and 07/16/23 revealed State Tested Nurse Aide (STNA) #160 and Licensed Practical Nurses (LPNs) #110 and #159 interviewed Resident #14, who reported STNA #126 took away the resident's call light and TV remote, held her tightly by the wrists, and forced her to wear double briefs. LPN #110 wrote in her statement that she observed Resident #14 wearing two briefs at the time of the skin assessment on 07/16/23.

During an interview on 07/18/23 at 9:30 A.M. the Administrator stated he was aware Resident #14 was wearing two briefs at the time LPN #110 assessed her. The Administrator stated this was not acceptable, standard practice, and STNA #126 would receive disciplinary action before returning to work.

Review of Resident Handbook revealed according to Ohio State Resident rights under the Ohio Revised Code, residents had the right to be free from all forms of abuse and were to be treated at all times with courtesy, respect, and full recognition of dignity and individuality.

This deficiency represents non-compliance investigated under Complaint Number OH00144514.

Based on medical record review, observation, resident interview, staff interview, and review of a facility policy, the facility failed to ensure fall interventions were in place per the resident's plan of care. This affected one (#63) of three residents reviewed for falls. The facility census was 110.

Findings include:

Review of the medical record for Resident #63 revealed an admission date of 04/21/21 with diagnoses including hereditary ataxia, atherosclerotic heart disease, cardiomyopathy, peripheral vascular disease (PVD), and sarcopenia.

Review of the Minimum Data Set (MDS) assessment for Resident #63 dated 04/07/23 revealed the resident was cognitively impaired and required extensive assistance of one to staff with activities of daily living (ADLs).

Review of the fall risk assessments for Resident #63 dated 02/28/23 and 05/30/23 revealed the resident was at risk for falls.

Review of the fall care plan for Resident #63 dated 11/23/22 revealed the resident was at risk for falls related to deconditioning, ataxia, and abnormal involuntary movements. Resident #63 had a history of staff observing him placing himself onto the floor mat from his bed. Interventions included a fall mat to the floor beside the bed, bed in low position, keep the call light in reach.

Observation on 06/09/23 at 12:38 P.M. revealed Resident #63 was in bed resting with the left side of bed pushed up against the wall. Resident #63's fall mat was folded up behind the headboard of the bed. Resident #63 did not respond to request for interview.

Interview on 06/09/23 at 12:39 P.M. with Licensed Practical Nurse (LPN) #840 confirmed Resident #63's fall mat was folded up and placed behind the headboard of his bed. LPN #840 confirmed she was unsure if Resident #63 was supposed to have a fall mat at his bedside, and was also unsure how long the mat had been folded up and stored behind the headboard of the bed.

Interview on 06/09/23 at 12:40 P.M. with Resident #62, who was Resident #63's roommate, confirmed Resident #63 was supposed to have a fall mat on the floor to right side of bed.

Interview on 06/09/23 at 1:05 P.M. with State Tested Nurse Aide (STNA) #845 confirmed Resident #63 had been in bed since 7:00 A.M. per his preference. STNA #845 confirmed there was a fall mat folded up behind Resident #63's headboard which had been in that location since the beginning of the shift on 06/09/23 at 7:00 A.M. STNA #845 confirmed she did not know Resident #63 was supposed to have a fall mat placed on the floor to the right side of the bed when he was in bed.

Interview on 06/09/23 at 2:19 P.M. with the Director of Nursing (DON) confirmed Resident #63 was supposed to have a fall mat to floor to the right side of his bed when he was in bed as part of his fall care plan.

Review of the facility policy titled, Falls and Fall Risk Managing

Based on medical record review, observation, staff interview, and review of a facility policy, the facility failed to ensure medications were administered as ordered. There were two medications errors observed out of 25 opportunities for a medication error rate of eight percent (8 %). This affected two (#101 and #103) of four residents observed for medication administration. The facility census was 110.

Findings include:

1. Review of the medical record for Resident #101 revealed an admission date of 05/12/23 with a diagnoses of multiple myeloma and pathological fractures due to neoplastic bone disease.

Review of the Minimum Data Set (MDS) assessment for Resident #101 dated 05/14/23 revealed the resident was cognitively impaired was totally dependent on staff assistance with activities of daily living (ADLs).

Review of the June 2023 monthly physician orders for Resident #101 revealed an order dated 05/13/23 for the resident to receive Oyster shell calcium 500 milligrams (mg) with vitamin D five (5) micrograms (mcg) one tablet daily.

Review of the June 2023 medication administration record (MAR) for Resident #101 revealed the Oyster shell calcium with vitamin D tablet was due to be administered at 8:30 A.M. The medication was not signed off as administered.

Observation of medication administration on 06/09/23 at 8:25 A.M. for Resident #101 per Licensed Practical Nurse (LPN) #830 revealed the Oyster shell calcium with vitamin D tablet was not available for administration.

Interview on 06/09/23 at 8:25 A.M. with LPN #830 confirmed the Oyster shell calcium with vitamin D tablet for Resident #101 was not available for administration.

2. Review of the medical record for Resident #103 revealed an admission date of 05/12/23 with diagnoses including unspecified dementia with behavioral disturbance, history of malignant neoplasm of bronchus and lung, heart disease, and major depressive disorder.

Review of the MDS assessment for Resident #103 dated 05/19/23 revealed the resident was cognitively impaired and required limited assistance of one staff with ADLs.

Review of the June 2023 monthly physician orders for Resident #103 revealed an order dated 05/19/23 for the resident to receive a vitamin D tablet 50,000 units once weekly on Fridays.

Review of the June 2023 MAR for Resident #103 revealed the resident was to receive a vitamin D tablet at 8:30 A.M. on Friday, 06/09/23. The medication was documented as not given.

Review of the laboratory results for Resident #103 dated 06/02/23 revealed the resident's vitamin D level was low at 19 nanograms (ng) per milliliter (mL) with a normal level between 30 ng/mL to 100 ng/mL.

Observation of medication administration on 06/09/23 at 8:59 A.M. for Resident #103 per LPN #830 revealed the vitamin D 50,000 units tablet was not available for administration.

Interview on 06/09/23 at 8:59 A.M. with LPN #830 confirmed the vitamin D 50,000 units tablet for Resident #103 was not available for administration.

Observation on 06/09/23 at 2:03 P.M. of the medication cart with LPN #830 revealed the Oyster shell calcium with vitamin D tablet was not available for Resident #101, and the vitamin D 50,000 units tablet was not available for Resident #103.

Interview on 06/09/23 at 2:03 P.M. with LPN #830 confirmed the Oyster shell calcium with vitamin D tablet for Resident #101 and the vitamin D tablet for Resident #103 were not available.

Interview on 06/09/23 at 3:53 P.M. with the Director of Nursing (DON) confirmed LPN #830 had not reported Resident #101's and #103's medications as not administered during medication administration on 06/09/23. The DON confirmed not giving the medications was an error of omission, and confirmed understanding the medication error rate for the observation on 06/09/23 was 8 %.

Review of the undated facility policy titled, Administering Medications

Based on record reviews, observations, interviews, and review of facility policy, the facility failed to ensure medication error rates did not exceed five percent (%). This affected one Resident (#9) out of three residents observed for medication administration. The facility census was 114.

Findings include:

A chart review revealed Resident #9 was admitted on 03/02/21 with diagnosis including hemiplegia/hemiparesis, Coronavirus (COVID-19), mood disorder, constipation, diabetes, hypertension, depression, anemia, convulsions ataxia, cerebral infarction, peripheral vascular disease, dysphagia, chronic pain, and hypertensive heart disease.

Review of the Quarterly Minimum Data Set dated 07/08/22 revealed Resident #9 had no cognitive deficits.

Review on physician orders for Resident #9 dated 05/24/22 revealed to give Lisinopril (anti-hypertension) 20 milligrams (mg) one time daily and to hold if systolic blood pressure (top number) was less than 110 millimeters of mercury (mm/Hg) (normal blood pressure is less than 120/80) and/or diastolic blood pressure (bottom number) was lower than 60 mm/Hg. Physician orders also revealed resident was ordered Amlodipine Besylate tablet (anti-hypertension) 10 mg one time daily and to hold if systolic blood pressure was less than 110 mm/Hg and/or diastolic blood pressure was lower than 60 mm/Hg.

Observation on 10/04/22 from 8:27 A.M. to 8:43 A.M. with Licensed Practical Nurse (LPN) #25 administering 20 medications to two Residents (#2 and #8) with no medication errors.

During continued observation of medication administration on 10/04/22 at 9:12 A.M. with LPN #20 revealed LPN #20 took Resident's #9 blood pressure in left wrist and it was 101/67 mm/Hg, then administered the following medications: Fiberlax capsules 625 mg, Lisinopril 20 mg, Amlodipine Besylate 10 mg, Aspirin 81 mg, Multivitamin one tablet, and Vitamin B-12 500 micrograms (mcg) two tabs. This brought the medication error rate of 27 administrations and two errors ending with medication error rate of 7.41 %.

Interview on 10/04/22 at 1:25 P.M. with LPN #20 verified that she gave Lisinopril 20 mg, and Amlodipine Besylate 10 mg and that she was unaware of the parameters set to hold if systolic blood pressure was less than 110 mm/Hg and/or diastolic blood pressure was lower than 60 mm/Hg for both medications.

Review of the Administering Medications Policy (dated 04/01/19) revealed the following information was checked/verified for each resident prior to administering medications: allergies to medications, and vital signs if necessary.

This complaint substantiates Master Complaint Number OH00136373 and Complaint Number OH00136331.

Based on record review and staff interview, the facility failed to ensure the medical record accurately reflected a resident's advance directive. This affected one (Resident #8) of 32 residents reviewed for advance directives. The facility census was 108.

Findings include:

Review of the clinical record revealed Resident #8 was admitted to the facility on 12/11/15. His diagnoses included hypertensive chronic kidney disease, obstructive and reflux uropathy, chronic kidney disease stage II, and vascular dementia with behavioral disturbance.

Review of the quarterly Minimum Data Set (MDS) assessment dated 06/16/22 revealed Resident #8 had moderate cognitive impairment.

Review of the electronic record revealed Resident #8 had an order for Do Not Resuscitate Comfort Care Arrest (DNR CC- Arrest) (protocol is activated when the patient experiences cardiac or respiratory arrest), dated 12/10/21.

Review of the hard chart revealed Resident #8 had an undated DNR-CC (DNR protocol is activated when the DNR order is issued) signed on the hard chart.

Interview on 09/20/22 at 11:01 A.M. with Licensed Practical Nurse (LPN) #116 revealed Resident #8's undated DNR-CC located in the hard chart was completed on 03/03/22. LPN #116 verified Resident #8's advance directives did not match in the electronic record and hard chart.

Based on observations, resident and staff interviews, medical record review, and policy review, the facility failed to ensure residents, who required extensive staff assistance or dependent on staff for activities of daily living (ADL) care, received adequate and timely hygiene care and assistance with meals. This affected three (Resident #18, #28 and #54) of five residents reviewed for ADL. The facility identified 102 residents who required assistance for dressing, 72 residents who required assistance with eating, and all 108 residents required assistance with bathing. The facility census was 108. Finding include: 1. Medical record review for Resident #54 revealed an admission date of 08/08/12. Diagnoses included dementia, hemiplegia and hemiparesis following cerebral infarction, osteoarthritis, cognitive communication deficit, and type II diabetes mellitus (DM). Review of the Minimum Data Set (MDS) 3.0 assessment dated 07/22/22 revealed Resident #54 had impaired cognition and was dependent on staff for personal hygiene. Review of the care plan, last revised 08/04/22, revealed Resident #54 has an ADL self-care performance deficit related to left sided paralysis following a cerebral infarction. She required assistance with all ADLs. Observation of Resident #54 on 09/19/22 at 1:07 P.M. revealed the fingernails on her left hand extended three-fourths inch past the fingertip and the fingernails of the right hand extended half-inch past the fingertip and were jagged. The fingernails had dark colored debris under them. Observation of Resident #54 on 09/20/22 at 11:46 A.M. revealed her fingernails no longer had debris beneath them and appeared clean. The fingernails remained the jagged and extended three-fourths inch past the fingertip on the left hand and half-inch on the right hand. Observations of Resident #54 on 09/21/22 at 9:44 A.M. and 09/22/22 at 9:10 A.M. revealed there was dark debris under the fingernails. The fingernails remained the jagged and extended three-fourths inch past the fingertip on the left hand and half-inch on the right hand. Interview with State Tested Nurses Aide (STNA) #121 on 09/21/22 at 9:49 A.M. confirmed the length of Resident #54's nails. She also confirmed Resident #54's nails were jagged and dirty underneath. STNA #121 stated the staff were not allowed to trim her nails and Resident #54 has a special physician that comes in to trim her nails. Interview with Director of Nursing (DON) on 09/21/22 at 2:50 P.M. confirmed Resident # 54's fingernails were long and jagged. The DON stated Resident #54 has a fungal issue with her fingernails and the facility staff were unable to trim her nails due to her DM, circulation, and the fungal issue. The facility had the podiatrist assess her nails and try to cut her nails. She stated the podiatrist recommended to refer to dermatology. The DON stated dermatology were unable to cut her nails. Review of the facility's policy titled Care of Fingernails/ToenailsBased on observations, resident and staff interviews, medical record review, and policy review, the facility failed to ensure residents, who required extensive staff assistance or dependent on staff for activities of daily living (ADL) care, received adequate and timely hygiene care and assistance with meals. This affected three (Resident #18, #28 and #54) of five residents reviewed for ADL. The facility identified 102 residents who required assistance for dressing, 72 residents who required assistance with eating, and all 108 residents required assistance with bathing. The facility census was 108.

Finding include:

1. Medical record review for Resident #54 revealed an admission date of 08/08/12. Diagnoses included dementia, hemiplegia and hemiparesis following cerebral infarction, osteoarthritis, cognitive communication deficit, and type II diabetes mellitus (DM).

Review of the Minimum Data Set (MDS) 3.0 assessment dated 07/22/22 revealed Resident #54 had impaired cognition and was dependent on staff for personal hygiene.

Review of the care plan, last revised 08/04/22, revealed Resident #54 has an ADL self-care performance deficit related to left sided paralysis following a cerebral infarction. She required assistance with all ADLs.

Observation of Resident #54 on 09/19/22 at 1:07 P.M. revealed the fingernails on her left hand extended three-fourths inch past the fingertip and the fingernails of the right hand extended half-inch past the fingertip and were jagged. The fingernails had dark colored debris under them.

Observation of Resident #54 on 09/20/22 at 11:46 A.M. revealed her fingernails no longer had debris beneath them and appeared clean. The fingernails remained the jagged and extended three-fourths inch past the fingertip on the left hand and half-inch on the right hand.

Observations of Resident #54 on 09/21/22 at 9:44 A.M. and 09/22/22 at 9:10 A.M. revealed there was dark debris under the fingernails. The fingernails remained the jagged and extended three-fourths inch past the fingertip on the left hand and half-inch on the right hand.

Interview with State Tested Nurses Aide (STNA) #121 on 09/21/22 at 9:49 A.M. confirmed the length of Resident #54's nails. She also confirmed Resident #54's nails were jagged and dirty underneath. STNA #121 stated the staff were not allowed to trim her nails and Resident #54 has a special physician that comes in to trim her nails.

Interview with Director of Nursing (DON) on 09/21/22 at 2:50 P.M. confirmed Resident # 54's fingernails were long and jagged. The DON stated Resident #54 has a fungal issue with her fingernails and the facility staff were unable to trim her nails due to her DM, circulation, and the fungal issue. The facility had the podiatrist assess her nails and try to cut her nails. She stated the podiatrist recommended to refer to dermatology. The DON stated dermatology were unable to cut her nails.

Review of the facility's policy titled Care of Fingernails/Toenails

Based on record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure fall prevention interventions were put in place for a resident at high risk for falls and per the resident's plan of care. This affected one (Resident #85) of five residents reviewed for accidents. The facility also failed to ensure resident smoking materials were safely stored and secured. This affected three (Residents #3, #68, and #97) of 18 facility identified residents who smoked. The facility census was 108.

Findings include:

1. Review of the medical record for Resident #85 revealed an admission date of 08/18/22. Diagnoses included laceration of trachea, fracture of the second cervical vertebra, and anxiety disorder.

Review of the Minimum Data Set (MDS) assessment dated 08/25/22 revealed Resident #85 was cognitively impaired and required extensive assistance of one to two staff with activities of living (ADLs.)

Review of the fall risk assessment dated 08/18/22 revealed Resident #85 was at a high risk for falls.

Review of the care plan dated 08/19/22 revealed Resident #85 had an actual fall and was at risk for falls. Interventions included fall mat and foam cushion wedge for positioning.

Review of the nursing progress note dated 08/19/22 revealed Resident #85 had an unwitnessed without injury which occurred when Resident #85 fell out of bed. Resident #85 was assisted back to bed; neurological checks were initiated, and a fall mat were placed beside the bed and side wedge with a foam cushion.

Review of the facility's fall risk investigation dated 08/19/22 revealed Resident #85 slid out of bed on 08/19/22 and the resident's care plan was updated with a new intervention: place fall mats at the bedside when the resident was in bed and use foam cushion wedge for positioning.

Observation on 09/20/22 at 10:19 A.M. revealed Resident #85 was resting in bed and had no fall mats or wedge cushion in his room.

Interview on 09/20/22 at 10:19 A.M. with Resident #85 confirmed he did not have fall mats or a wedge cushion in his room and he didn't think he had them since he moved to his current room a week or two ago.

Interviews on 09/20/22 at 10:31 A.M. with Registered Nurse (RN) #17 and State Tested Nursing Assistant (STNA) #93 confirmed Resident #85 did not have a fall mat or wedge cushion in his room. RN #17 further confirmed Resident #85 had lived on a different floor when he fell on 08/19/22 and she wondered if maybe the devices hadn't been moved down with him.

Interview on 09/21/22 at 11:00 A.M. with the Director of Nursing (DON) confirmed Resident #85 should have fall mats at the bedside when in bed a foam wedge cushion for positioning in bed to help prevent falls and to help minimize the risk of injury from falls based upon the Interdisciplinary Team (IDT) follow up fall investigation completed on 08/19/22.

Review of the facility's policy titled Falls Clinical Protocol

Based on record review and staff interview, the facility failed to ensure a resident who was at nutrition risk and had a unplanned significant weight loss received a timely nutritional assessment and intervention(s). This affected one (Resident #47) of seven residents reviewed for nutrition. The facility identified eight resident with unplanned significant weight loss/gain. The facility census was 108.

Findings include:

Review of Resident #47's medical record revealed Resident #47 was admitted to the facility on 06/22/22. Diagnoses included cerebral infarction, severe protein-calorie malnutrition, diverticulosis, hyperlipidemia, vitamin D deficiency, cerebral atherosclerosis, acute kidney failure, and dysphagia.

Review of the quarterly Minimum Data Set (MDS) assessment dated 07/18/22 revealed Resident #47 was severely cognitively impaired and he required extensive assistance for eating.

Review of the quarterly nutrition assessment dated 07/19/22 revealed Resident #47 was on a regular diet with mechanical texture. His intake was zero to 25% at meals and he received Ensure Plus (a high calorie nutritional supplement) three times daily with variable intake.

Review of the care plan dated 09/06/22 revealed Resident #47 was at nutritional risk due to diagnoses of cerebral infarction, protein calorie malnutrition, diverticulosis, and aphasia. In addition, he had a need for a therapeutic diet and tube feeding to provide additional nutrition.

Review of the physician's orders revealed Resident #47 was on a regular diet with mechanical soft texture and required a bolus tube feeding after every meal if he consumed less than 50% of his meal.

Review of the weight record revealed Resident #47 weighed 122.6 pounds on 08/12/22 and had weighed 109 pounds on 09/06/22 and for a significant weight loss of 11.1% over one month.

From 09/06/22 to 09/21/22, there was nothing in the medical record addressing Resident #47's significant weight loss. On 09/22/22, a re-weight of 112 pounds was obtained, which indicated a 8.65% significant weight loss from 08/12/22.

Interview on 09/22/22 with Registered Dietician (RD) #165 reported she did not think Resident #47 had a significant weight loss as he looked the same. RD #165 stated she thought the 09/06/22 weight was incorrect and had requested a reweigh. RD #130 reported since she did not think Resident #47 had a significant weight loss she had not put any interventions in place pending the new weight. She stated she had checked weekly but had not received a new weight and had no explanation for this delay.

Interview on 09/22/22 at 11:30 A.M. with Licensed Practical Nurse (LPN) #116 reported Resident #47's appetite and intake fluctuated. She stated she fed him yesterday, he ate less than 50% and received a bolus tube feeding. She reported she was not sure why he had not been reweighed per the request of the RD.

Based on record review, resident and staff interview, and review of the facility policy, the facility failed to ensure residents received medications as physician ordered. This affected one (Resident #85) of five residents reviewed for medications. The facility census was 108.

Findings include:

Review of the medical record for Resident #85 revealed an admission date of 08/18/22 with diagnoses including laceration of trachea, fracture to the second cervical vertebra, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated 08/25/22 revealed Resident #85 was cognitively intact.

Review of the hospital continuity of care form dated 08/18/22 revealed Resident #85 had an order to receive a Lovenox (anticoagulant) injection once daily at bedtime.

Review of the admission orders dated 08/18/22 revealed Resident #85 had an order to receive a Lovenox injection once daily at bedtime.

Review of the care plan dated 08/29/22 revealed Resident #85 was at risk for developing complications secondary to having anticoagulant therapy related to prophylaxis due to reduced mobility. Interventions included to administer medications as ordered.

Review of the nurse progress notes for Resident #85 dated 09/07/22 through 09/13/22 revealed Lovenox was not administered because it was not available from the pharmacy.

Review of the September 2022 Medication Administration Record (MAR) for Resident #85 revealed Lovenox was not administered seven days on 09/07/22, 09/08/22, 09/09/22, 09/10/22, 09/11/22, 09/12/22, and 09/13/22.

Interview on 09/20/22 at 10:08 A.M. with Resident #85 stated the facility ran out of his Lovenox for at least a week earlier in the month of September 2022.

Interview on 09/22/22 at 1:57 P.M. with the Director of Nursing (DON) confirmed Resident #85 did not receive his Lovenox as ordered by the physician from 09/07/22 to 09/13/22.

Review of the facility's policy titled Administering Medications

Based on record review, staff interview, and review of the facility policy, the facility failed to ensure residents on as needed anti-anxiety medications had a duration or stop date for the medication. This affected one (Resident #85) of five residents reviewed for unnecessary medications. The facility identified seven residents with orders for anti-anxiety medications. The facility census was 108.

Findings include:

Review of the medical record for Resident #85 revealed an admission date of 08/18/22 with diagnoses including anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated 08/25/22 revealed Resident #85 was cognitively intact.

Review of the physician orders dated 08/24/22 revealed Resident #85 had an order to receive Ativan as needed for anxiety. The physician order did not include a stop date.

Review of the care plan dated 08/29/22 revealed Resident #85 used anti-anxiety medications related to anxiety disorder. Interventions included the following: administer anti-anxiety medications as ordered by the physician, monitor for side effects and effectiveness, educate the resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms, monitor the resident for safety as resident was taking medication which was associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls, broken hips, and legs.

Review of the August and September 2022 Medication Administration Record (MAR) revealed Resident #85 received as needed doses of Ativan on the following dates: 08/22/22, 08/24/22, 08/28/22, 08/29/22, 08/30/22, 09/06/22, 09/07/22, 09/08/22, 09/09/22, 09/10/22, 09/11/22, and 09/12/22.

Interview on 09/22/22 at 1:57 P.M. with the Director of Nursing (DON) confirmed Resident #85's as needed Ativan order did not include a stop date.

Review of the facility's policy titled Psychotropic Medication Use

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure expired medications were discarded. This affected the following residents (Residents #33, #34, #36, #72, and #202) of 25 facility identified residents receiving insulin. This had the potential to affect Residents #57, #58, #70, and #85 who resided on the second floor with orders for bisacodyl suppositories. This had the potential to affect Residents #36 and #70 who resided on the second floor with orders for promethazine suppositories. This had the potential to affect all residents on the second floor with the exception of Residents #91 and #94 who the facility identified as having contraindication to receiving tuberculin skin testing solution. The facility census was 108.

Findings include:

1. Observation on 09/21/22 at 1:14 P.M. of the second-floor medication room with Registered Nurse (RN) #175 revealed the medication refrigerator contained an open and undated bottle of tuberculin testing solution, a box of bisacodyl suppositories with a manufacturer's expiration date of 12/2021, and a bag containing four promethazine suppositories with a manufacturer's expiration date of 12/2021.

Interview on 09/21/22 at 1:14 P.M. with RN #175 confirmed the second-floor medication room refrigerator contained undated opened tuberculin testing solution and outdated bisacodyl and promethazine suppositories. RN #175 confirmed tuberculin testing solution should be dated upon opening and discarded within 30 days and the outdated suppositories should be discarded.

Review of the facility's list of residents with medications on the second floor revealed Residents #57, #58, #70, and #85 had physician orders for bisacodyl suppositories. All residents on the second floor had the potential to receive a tuberculin skin test with the exception of Residents #91 and #94 who the facility identified as having contraindication to receiving tuberculin skin testing solution. Residents #36 and #70 had physician orders for promethazine suppositories.

2. Observation on 09/21/22 at 2:00 P.M. of the first floor medication cart with Licensed Practical Nurse (LPN) #200 revealed there was a Novolog insulin pen for Resident #33 dated as opened on 08/06/22, a Novolog pen for Resident #34 which was open and undated, a Humalog insulin pen for Resident #36 which was dated as opened on 08/06/22, a Levemir insulin pen for Resident #72 which was dated as opened on 08/13/22, and an insulin glargine pen for Resident #202 which was not dated upon opening.

Interview on 09/21/22 at 2:01 P.M. with LPN #200 confirmed insulin should be dated upon opening and should be discarded in 30 days. LPN #200 stated if there was no date upon opening, she was unsure if the medication was expired or not. LPN #200 confirmed the insulin for Residents #33, #36, and #72 was expired and should have been discarded.

Review of the facility's policy titled Storage of Medications

Based on observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure food was served at safe and appropriate temperatures. This had the potential to affect all residents residing in the facility with the exception of five residents (Residents #52, #63, #70, #77 and #92) identified by the facility as not receiving food prepared in the facility kitchen. The facility census was 108.

Findings include:

Interview on 09/19/22 at 12:42 P.M. with Resident #3 stated the food at the facility was served cold.

Interview on 09/21/22 at 11:15 A.M. with Dietary Supervisor (DS) #63 reported she had not heard any complaints about the temperature of the food.

Observation of the tray line on 09/21/22 at 12:12 P.M. revealed the food was the following temperatures: baked beans were 151 degrees Fahrenheit (F), hot dogs were 160 degrees F and the potato salad was 40 F. Hot plates were not utilized for the resident's plates as DS #63 stated she did not want the potato salad to get warm.

Observation of a test tray on 09/21/22 with DS #63 revealed the hot cart left the kitchen at 1:38 P.M. and was served at 1:51 P.M. The temperatures were as follows: hot dogs 100 degrees F, baked beans 80 degrees F, potato salad was 64 degrees F and the juice was 50 degrees F. The potato salad was barely cool when tasted and the hot dog and baked beans were lukewarm. The temperatures of the food were competed and verified with DS #63.

Interview on 09/22/22 at 9:14 A.M. with Resident #97 stated her lunch meal yesterday of a hot dog and baked beans were cold. She also stated her breakfast today of scrambled eggs and a ham slice were cold.

Interview on 09/22/22 at 10:33 A.M. with Registered Dietitian (RD) #130 reported there was not a certain temperature the food needed served to residents but it should be palatable.

Interview on 09/22/22 at 11:15 A.M. with Resident #23 reported the hot dog served for lunch yesterday was cold and she placed it in the microwave to warm it up. She also stated the potato salad was not cold.

Review of the facility's policy titled Food Preparation and Service