Harrison Pavilion Care Center

Based on staff and resident interviews, medical record review, review of Self-Reported Incident (SRI), review of police report, and policy review, the facility failed to ensure a resident was free from abuse. This affected one (#34) resident out of four residents reviewed for abuse. The facility census was 80.

Findings included:

1. Review of the medical record for Resident #34 revealed an admission date of 07/19/16 with medical diagnoses of hypertension (HTN), nephrotic syndrome, heart disease, chronic obstructive pulmonary disease (COPD), and schizophrenia.

Review of the medical record for Resident #34 revealed a quarterly Minimum Data Set (MDS), dated 01/02/24, which indicated Resident #34 was cognitively intact and was independent with eating, toilet hygiene, bed mobility, and transfers. The MDS did not indicate any behaviors.

Review of the medical record for Resident #34 revealed a nurse progress note, dated 01/08/24 at 6:00 A.M. with stated Resident #34 reported to the nurse that his roommate, Resident #84, was physically aggressive towards him which was witnessed by staff. The note continued to state the two (#34 and #84) residents were separated, assessments were completed, and the physician was notified. The note stated no injuries were noted.

2. Review of the medical record for Resident #84 revealed an admission date of 11/11/23 with medical diagnoses of HTN, peripheral neuropathy, anxiety, diabetes mellitus, and chronic pain syndrome. Review of the medical record for Resident #84 revealed a discharge date of 02/13/24.

Review of the medical record for Resident #84 revealed an admission MDS, dated 11/17/23, which indicated Resident #84 was cognitively intact and required supervision with toilet hygiene, bed mobility, and transfers. The MDS did not indicate any behaviors.

Review of the medical record for Resident #84 revealed a nurse progress note, dated 01/08/24 at 6:19 A.M., which stated Resident #84 initiated physical aggression towards his roommate Resident #34. The note stated Resident #84 informed the nurse that Resident #34 hit him on the left hip and lower back with the bathroom door before leaving their room. The note continued to state Resident #84 followed Resident #34 out into the hallway and started to hit Resident #34 with his walker in his back. The note stated the residents were separated and skin assessments were completed with no injuries noted.

Interview on 2/15/24 at 10:01 A.M. with Resident #34 confirmed Resident #84 hit him with his walker in the hallway which was witnessed by staff. Resident #34 stated he had a little pain at the time of the incident but denied any injuries . Resident #34 stated the incident was unprovoked and denied hitting Resident #84 while in their room. Resident #34 stated Resident #84 was moved to a different room and there were no further incidents between the two residents.

Interview on 02/15/24 at 10:56 A.M. with Licensed Practical Nurse (LPN) #122 confirmed she witnessed Resident #84 intentionally hit Resident #34 with his walker while in the hallway on 01/08/24. LPN #122 stated she separated the residents and Resident #34 called the police to report the altercation.

Interview on 02/15/24 at 12:00 P.M. with Director of Nursing (DON) stated an investigation was completed on 01/08/24 into the allegation of abuse by Resident #84 to Resident #34. DON stated she did not substantiate the allegation because she did not believe Resident #84 intentionally hit Resident #34 with his walker. DON stated Resident #84 was moved to a different room and there were no further incidents between the two residents.

Review of the SRI report, dated 01/08/24, stated Resident #84 was observed by staff throwing his walker at Resident #34 and hitting him in the back. The report stated no injuries were noted and an investigation was completed. The facility did not substantiate the allegation of abuse.

Review of the police report dated 01/08/24, Resident #84 was charged with simple assault.

Review of the facility policy titled, Abuse and Neglect Protocols, stated residents have the right to be free abuse, neglect, misappropriation or resident property, exploitation, corporal punishment, physical or chemical restraints. The policy stated abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resident physical harm, pain, or mental anguish.

This deficiency represents non-compliance investigated under Complaint Numbers OH00150614 and OH00150334.

Based on medical record review and staff and pain specialist staff interviews, the facility failed to ensure a pain specialist appointment was scheduled and failed to effectively manage a resident's pain. This affected one (#84) resident out of three residents reviewed for pain management. The facility census was 80.

Findings included:

Review of the medical record for Resident #84 revealed an admission date of 11/11/23 with medical diagnoses of HTN, peripheral neuropathy, anxiety, diabetes mellitus, and chronic pain syndrome. Review of the medical record for Resident #84 revealed a discharge date of 02/13/24.

Review of the medical record for Resident #84 revealed an admission Minimum Data Set (MDS), dated 11/17/23, which indicated Resident #84 was cognitively intact and required supervision with toilet hygiene, bed mobility, and transfers.

Review of the medical record for Resident #84 revealed a Nurse Practitioner (NP) note, dated 01/18/24, which revealed Resident #84 stated his current pain management was no longer working for his pain and Resident #84 asked for a pain management referral. The note stated Resident #84 rated his pain a seven out of ten on the pain scale.

Review of the medical record for Resident #84 revealed a physician order, dated 11/14/23, for Norco 7.5-325 milligram (mg) one tablet by mouth every six hours as needed for pain and an order dated 11/11/23 for gabapentin 600 mg one tablet by mouth three times per day for pain. Further review of the physician orders revealed an order dated 01/29/24 for a consultation for pain management.

Review of the medical record for Resident #84 revealed a nurse's note, dated 01/29/24 at 8:16 P.M. that stated a pain specialist office was contacted per the order and Resident #84's medical information was faxed to the office. The note stated the nurse was informed by the office staff that a determination would be made in three to four days if the pain specialist would accept Resident #84. Further review of the medical record revealed no documentation to support Resident #84 was scheduled an appointment with the pain specialist or that the facility followed up on the referral.

Interview on 02/15/24 at 11:27 A.M. with Receptionist #210 from pain specialist office stated there was no documentation to support their office received a referral for Resident #84.

Interview on 02/15/24 at 11:48 A.M. with Director of Nursing (DON) confirmed the facility staff did not follow up with the pain specialist office to schedule Resident #84's consultation appointment. DON also confirmed the medical record for Resident #84 did not contain any documentation to support the facility staff adjusted Resident #84's pain medications or offered other non-pharmacological interventions to effectively manage his pain.

This deficiency represents non-compliance investigated under Complaint Number OH00150614.

Based on medical record review, observation, staff interview, and review of facility policies, the facility failed to follow infection control guidelines when administering medications. This affected one (#70) out of three residents reviewed for medication administration. The facility census was 80.

Findings included:

Review of the medical record for Resident #70 revealed an admission date of 03/19/08 with medical diagnoses of depression, diabetes mellitus (DM), hypertension (HTN), chronic obstructive pulmonary disease, dementia, and schizoaffective disorder.

Review of the medical record for Resident #70 revealed a quarterly Minimum Data Set (MDS), dated 01/12/24, which indicated Resident #70 had moderate cognitive impairment and was independent with eating, bed mobility and transfers.

Review of the medical record for Resident #70 revealed a physician order dated 11/27/21 for metformin 500 milligram (mg) one tablet by mouth daily for DM, an order dated 01/13/22 for metoprolol 25 mg one tablet by mouth daily for HTN, and an order dated 06/30/22 for Risperdal one mg one tablet by mouth three times per day for schizoaffective disorder.

Observation on 02/14/24 at 8:35 A.M. of Licensed Practical Nurse (LPN) #196 administering medications to Resident #70 revealed LPN #196 placed the metoprolol 25 mg tablet, the metformin 500 mg tablet, and the Risperdal one mg tablet directly into her bare hand from the pill card and then placed the medications into the pill cup. LPN #196 was observed handing the pill cup with the medications to Resident #70 who consumed the medication in the presence of LPN #196. LPN #196 did not wash her hands, use hand sanitizer, or use gloves before or after administering medications to Resident #70.

Interview on 02/14/24 at 8:45 A.M. with LPN #196 confirmed she placed Resident #70's metoprolol, metformin, and Risperdal tablets directly into her bare hand then placed the medications into the pill cup prior to administering the medications to Resident #70. LPN #196 also confirmed she did not perform hand hygiene prior to or after administering medications to Resident #70.

Review of the facility policy titled, Administering Medications stated the staff should follow infection control procedures (e.g. handwashing, antiseptic technique, gloves) for administering medications.

Review of the facility policy titled Handwashing/Hand hygiene, revised August 2019, stated hand hygiene is the primary means to prevent the spread of infections.

This deficiency is based on incidental findings discovered during the course of this complaint investigation.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE 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, and staff 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 (Residents #3, #25, #37, and #42) of four residents reviewed for medications administered by a contracted ancillary provider. This affected 26 current residents (#3, #4, #10, #13, #14, #15, #18, #25, #30, #31, #34, #35, #37, #41, #42, #44, #46, #50, #56, #63, #66, #67, #69, #78, #79 and #81) and twelve discharged residents (#85, #86, #88, #89, #90, #91, #92, #93, #94, #95, and #96) identified by the facility who received IV fluids from the unlicensed source. The facility census was 80.

Findings include:

1. Record review for Resident #3 revealed the resident admitted to the facility on 05/27/22. Diagnoses included protein-calorie malnutrition, hypertension, and seizures.

Review of the Brief Interview for Mental Status (BIMS) assessment dated 09/17/23 revealed Resident #3 had intact cognition.

Review of the physician orders dated 06/05/23, 07/18/23, and 08/14/23 revealed Resident #3 had orders start a peripheral IV for 500 milliliter (ml) IV Micronutrient Hydration Therapy-Hydration Infusion (for overall support for multiple comorbidities) (Vitamin C, B Complex, B1, B2, B3, B4, B5, B6, B12, Magnesium Chloride, Calcium Gluconate, and Zinc) and 500 ml of Normal Saline (NS) 0.9 percent (%) for fluids. On 04/26/23 this resident received a Nutritional Infusion (for malnutrition) (Vitamin C, B Complex, B1, B2, B3, B4, B5, B12, Magnesium Oxide, Calcium Gluconate, Zinc, Amino, Glutamine, Arginine, Orthinine, Lysine, Citrulline, and BCAA.)

Review of the Medication Administration Record (MAR) revealed Resident #3 received IV Micronutrient Hydration Therapy - Infection Infusion from a contracted company on 04/26/23, 06/08/23, 07/19/23, and 08/16/23. All the IV Micronutrient Hydration Therapy-Infection Infusion administrations were completed by an ancillary provider not employed at the facility.

2. Record review for Resident #25 revealed the resident was admitted to the facility on 05/19/21. Diagnoses included altered mental status, dementia, psychoactive substance abuse, schizophrenia, and COVID-19.

Review of the Brief Interview for Mental Status (BIMS) assessment dated 11/08/23 revealed Resident #32 had impaired cognition.

Review of the physician orders dated 04/05/23 revealed Resident #25 had an order dated 04/05/23, 05/24/23, 06/05/23,07/19/23, and 08/14/23 to start a peripheral IV for IV Micronutrient Hydration Therapy - Cognition Infusion (Vitamin C, B-Complex, B-1, B2, B3, B5, B-6, Biotin, B-12, Magnesium Chloride, Calcium Gluconate, Zinc, Amino Blend, Glutamine, Arginine, Omithine, Lysine, Citrulline, Taurine, and Glycine) 1,000 ml with 1,000 ml of NS 0.9%.

Review of the Medication Administration Record (MAR) revealed Resident #25 received the IV Micronutrient Hydration Therapy - Cognition Infusion with NS 0.9% on 04/26/23, 05/24/23, 06/07/23, 07/19/23, and 08/16/23. All the IV Micronutrient Hydration Therapy - Cognition Infusion administrations were completed by an ancillary provider not employed at the facility.

3. Record review for Resident #37 revealed the resident was admitted to the facility on 09/30/21. Diagnoses included multiple sclerosis, protein-calorie malnutrition, hyperkalemia, and cirrhosis of the liver.

Review of the Brief Interview for Mental Status (BIMS) assessment dated 10/15/23 revealed Resident #37 had intact cognition.

Review of the physician orders dated 04/05/23, 06/05/23, and 07/18/23 revealed Resident #37 had an order to start a peripheral IV for IV Micronutrient Hydration Therapy - Derma and Infection Infusion (Vitamin C, B-Complex, B1, B2, B3, B5, B6, B12, Magnesium Chloride, Calcium Gluconate, Zinc, Amino Blend, Glutamine, Arginine, Ornthine, Lysine, Citrulline, BCAAA, B7 Biotin, and Glutathione) 500 milliliters (ml) per hour with 500 ml of Normal Saline (NS) 0.9% due to wound management and infections. On 08/14/23, a Hydration Infusion for hydration (Vitamin C, B Complex, B1, B2, B3, B4, B5, B6, B12, Magnesium Chloride, Calcium Gluconate, and Zinc) 250 ml at 250 ml per hour.

Review of the Medication Administration Record (MAR) revealed Resident #37 received the IV Micronutrient Hydration Therapy -with NS 0.9% on 04/26/23, 06/07/23, 07/19/23, and 08/16/23 All the IV Micronutrient Hydration Therapy - Nutrition Infusion administrations were completed by an ancillary provider not employed at the facility.

4. Record review for Resident #42 revealed the resident was admitted to the facility on 03/15/23. Diagnoses included hypertension, Alzheimer's disease, edema, dermatitis, and other infectious or parasitic diseases.

Review of the Brief Interview for Mental Status (BIMS) assessment dated 08/30/23 revealed Resident #42 had intact cognition.

Review of the physician orders dated 04/05/23, 05/24/23, 06/07/23, 07/19/23 and 0814/23 revealed Resident #42 had an order to start a peripheral IV for IV Micronutrient Hydration Therapy -Cognition Infusion (Vitamin C, B-Complex, B-1, B2, B3, B5, B-6, Biotin, B-12, Magnesium Chloride, Calcium Gluconate, Zinc, Amino Blend, Glutamine, Arginine, Omithine, Lysine, Citrulline, Taurine, and Glycine) 1,000 ml with 1,000 ml of NS 0.9%.

Review of the Medication Administration Record (MAR) revealed Resident #42 received the IV Micronutrient Hydration Therapy - Nutrition Infusion with NS 0.9% on 05/11/23, 06/08/23, and 07/13/23. All the IV Micronutrient Hydration Therapy - Cognition Infusion administrations All the IV Micronutrient Hydration Therapy - Cognitive Infusion administrations were completed by an ancillary provider not employed at the facility.

Review of the facility's contract with the ancillary provider revealed the contract was entered into agreement on 01/24/23. This provided for a monthly clinic to be provided to residents with various deficiencies. The type of therapy was administered per physician orders by contracted staff through the ancillary provider.

Interview with the Corporate Vice President of Operations (CVOP) #60 on 12/06/23 at 9:50 A.M. confirmed the facilities entered into the contract with the ancillary provider on 01/24/23 and began treatment clinics in March 2023. CVOP #60 verified the ancillary provider brought their own supplies and IV products to the facility. CVOP #60 verified the ancillary provider was based out of Illinois and used their own staff for IV administration. CVOP #60 verified she was never provided with the company's Ohio Terminal Distributor of Dangerous Drugs (TDDD) license. CVOP #60 verified the above listed residents received IV infusions of medications supplied by an unlicensed ancillary provider.

Interview with Chief Executive Officer #80 from the ancillary provider on 12/06/23 at 9:55 P.M. verified his company did not have and did not ever have an Ohio TDDD license to provide drugs in the State of Ohio, as he did not understand the specific Ohio laws. He verified a Cease-and-Desist order was given in September 2023, and no further infusions had taken place after this order. He verified two of his nurses would come in the facility and provide services, one with an Ohio license and the other with a reciprocal license from the state of Indiana to practice in Ohio.

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, repackager, 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, repackager, or wholesale distributor; or (4) A terminal distributor, manufacturer, outsourcing facility, third-party logistics provider, repackager, 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.

The deficient practice was corrected on 11/21/23 when the facility implemented the following corrective actions:

The company no longer serves the facility with cessation of services effective on 09/22/23.

All residents that receidved services from the company have been properly assessed by the DON/designee and do not have any signs or symptoms of adverse effects related to IVF/medications received on or before 11/21/23.

All residents with prior services from the company are at risk of this alleged deficient practice.

This service from the company is no longer being offered effective 09/22/23.

All contracts that involve providing medication were reviewed to ensure the proper TDDD licensure is in place, completed on or before 11/21/23.

Education was provided to the governing body to ensure that TDDD licensure for Ohio is effective before accepting medication into the facility or completion of administration was completed on or before 11/21/23. This was completed by the Director of Clinical Services #99.

Administrator/designee will complete audits of any company providing any pharmacy services to ensure that the appropriate TDDD license is effective in the State of Ohio. Audits will be completed weekly for one month and then monthly for three months. All audits will be provided to QAPI for review, effective 11/21/23.

This deficiency represents non-compliance investigated under Complaint Number OH00148108.

Based on record review, staff interview, resident interview, and review of the policy, the facility failed to ensure residents were invited to their care plan meetings. This affected four (#18, #28, #47, and #233) of four residents reviewed for care conferences. The facility census was 83.

Findings include:

1. Review of Resident #18's medical record revealed she an admission date of 09/25/20, with diagnoses including: anemia, coronary artery disease (CAD), hypertension, gastroesophageal reflux disease (GERD), diabetes mellitus 2 (DM2), hyponatremia, hyperlipidemia, anxiety disorder, depression, asthma, respiratory failure, and schizophrenia. Review of Resident #18's care conferences revealed her last completed care conference was 12/09/21.

Review of the annual Minimum Data Set (MDS) assessment, dated 08/11/23, revealed Resident #18 was cognitively intact. Further review of the MDS assessment revealed she required limited assistance from staff with bed mobility, transfers, and toilet use. Resident #18 required supervision from staff with walking and personal hygiene. Resident #18 was independent with eating. Review of Resident #18's care conferences revealed her last completed care conference was 12/09/21.

Interview on 09/25/23 at 10:55 A.M., with Resident #18 revealed she could not remember the last time she had a care conference to discuss her plan of care with the care team. Resident #18 stated it was a long time ago.

2. Review of Resident #28's medical record revealed an admission date of 05/17/22 and readmitted on 09/18/23 from the hospital. His diagnoses included alcohol induced persisting dementia, history of traumatic brain injury, dysphagia, diabetes mellitus 2, major depressive disorder, hyperlipidemia, anxiety disorder, major depressive disorder, alcohol dependence, and hypertension.

Review of the discharge MDS assessment for Resident #28, dated 09/13/23 revealed he had moderately impaired cognition. Further review of the MDS assessment revealed he required supervision from staff with dressing, eating, toilet use, and personal hygiene.

Interview on 09/26/23 at 9:06 A.M., with Resident #28 revealed he had never had a care conference with the care team to discuss his plan of care.

3. Review for Resident #47's medical record revealed an admission date of 05/09/23. Her diagnoses included heart failure, hypertension, DM2, and hyperlipidemia.

Review of the quarterly MDS assessment, dated 08/15/23, for Resident #47 revealed she was cognitively intact. Further review of the MDS assessment revealed she required extensive assistance from staff with bed mobility, dressing, and personal hygiene. Resident #47 was totally dependent on staff for assistance with transfers and toilet use. Resident # 47 was independent with eating.

Interview on 09/24/23 at 2:14 P.M., with Resident #47 revealed she had never met with the care team and had a care conference to discuss her plan of care.

4. Review of Resident #233 revealed she was admitted to the facility on 07/24/23. Her diagnoses included chronic obstructive pulmonary disease (COPD), hypercalcemia, DM2, tachycardia, respiratory failure with hypoxia, opioid dependence, depression, hyperlipidemia, obesity, and cognitive communication deficit.

Review of the new admission MDS for Resident #233, dated 08/27/23 revealed she was cognitively intact. Further review of the MDS assessment revealed she required limited assistance from staff with bed mobility, transfers, toilet use, and personal hygiene. Resident #233 revealed she was independent with eating.

Interview on 09/26/23 09:06 A.M., with Resident #233 revealed she had never had a care conference to discuss her plan of care with the care team at the facility.

Interview on 09/27/23 at 3:02 P.M., with the Social Service Director (SSD) #84 confirmed the last care conference for Resident #18 was completed on 03/29/22. SSD #84 confirmed Residents #28, #47, and #233 have never had a care conference following their admission to the facility. SSD #84 confirmed the facility should schedule care conferences for new admissions to the facility and quarterly during the Resident assessment.

Review of the facility policy titled, Resident Participation, dated 2016, revealed the resident or resident representative are encouraged to participate in the resident's assessment and in the development and implementation of a Resident's plan of care. Further review of the facility policy revealed, a comprehensive care plan is developed within seven days of completing a resident assessment.

Based on record review, observation, resident interview, and staff interview, the facility failed to ensure a resident was provided the assistance to obtain a pair of shoes. This affected one (#64) of 24 residents sampled during the annual survey. The facility census was 83.

Findings included:

Review of Resident #64's medical record revealed an admission date of 12/14/22. His diagnoses included atherosclerotic heart disease, essential tremor, intellectual disabilities, osteoarthritis, cervical disc degeneration of the cervical region, intervertebral disc degeneration of the lumbar region, chronic pain syndrome, ischemic cardiomyopathy, personal history of traumatic brain injury, occlusion and stenosis of the bilateral carotid arteries, hypothyroidism, type II diabetes, with diabetic neuropathy, and muscle weakness.

Review of the quarterly Minimum Data Set (MDS) assessment dated 07/12/23 revealed he was cognitively intact and needed supervision for activities of daily living.

Review of Resident #64's podiatry visit note dated 08/15/23 revealed under footwear evaluation the resident was counseled on proper footwear. The details included wearing well-fitting comfortable shoes. It noted he was in a risk category of loss of protective sensation with weakness, deformity, pre-ulcer, or callus but no history of ulceration.

Review of the funds balance revealed on 10/02/23 the resident had $1,600.59, which was sufficient to cover the cost of a pair of new shoes.

Observations on 09/26/23 at approximately 11:30 A.M. and again on 10/02/23 at 2:10 P.M., revealed Resident #64 was wearing non-skid socks and had a soft pair of slip-on house shoes next to the bed.

Interview on 09/26/23 at approximately 11:30 A.M., with Resident #64 stated he wanted diabetic shoes, but no one had ordered him any. Resident #64 stated the only shoes he had were two pair of soft house shoes. Resident #64 stated someone had given him a pair of shoes that did not fit. Resident #64 stated one of the shoes did not have a shoestring, so they were given to another resident.

Interview on 10/02/23 at 12:47 P.M., with the Administrator revealed the facility did not get Resident #64 any diabetic shoes due to the podiatrist not writing an order for them. The Administrator stated the podiatrist would be the one to request the shoes.

4. Observation on 09/25/23 at 11:15 A.M., revealed a strong and foul smelling odor was noted in one of the residential hallways and identified as coming from Resident #36's room.

Interview on 09/25/23 at 11:15 A.M., with Occupational Therapist #41 verified there was a strong odor in the hallway radiating from Resident #36's room.

Interview on 09/25/23 at 11:29 A.M., with Resident #36 stated he had some old rotted food he forgot about in his room and it spilled.

Review of the policy titled, Quality of Life-Homelike Environment, dated May 2017 stated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Further review of the policy revealed the facility and staff shall maximize the characteristics of the facility to reflect a homelike setting including a clean, sanitary, and orderly environment. The policy stated, staff shall provide person-centered care that emphasizes the resident's comfort, independence, and personal needs and preferences.

This deficiency represents noncompliance discovered during complaint investigation of Complaint Numbers OH00146517, OH00146416, OH00146414, and OH00146234.

Based on record review, and staff interview, the facility failed to complete a Significant Change Pre-Admission Resident Review (PASARR) for Resident #24. The facility failed to complete a PASARR review for Resident #63 in a timely manner following the expiration of the Hospital Exemption Notification System (HENS) approved stay at the facility. The facility failed to ensure Resident #70's PASARR was completed correctly by failing to identify mental health diagnoses. This affected three (#24, #63 and #70) of three residents reviewed for PASARR. The facility census was 83.

Findings include:

1. Record review for Resident #24 revealed he was admitted to the facility on 05/19/21. His diagnoses included antisocial personality, major depressive disorder, schizoaffective disorder, insomnia, bipolar disorder, depression, and altered mental status.

Review of quarterly Minimum Data Set (MDS) assessment, dated 08/29/23, revealed Resident #24 was cognitively intact. The MDS assessment revealed he required extensive assistance from staff with bed mobility, transfers, and eating. Resident #24 was totally dependent on staff with toilet use, transfers, and personal hygiene. Further review of the MDS assessments revealed Resident # 24 had a Significant Change MDS assessment completed on 01/11/23 related to an acute hospital stay.

Review of the Preadmission Screening and Resident Review for Resident (PASARR) for Resident #24 revealed the only PASARR in place was dated, 02/07/22. The facility failed to submit a PASARR for Resident #24 related to his significant change in health dated 01/11/23.

2. Record review for Resident #63 revealed she was admitted to the facility on 11/28/22. Her diagnoses included acute and chronic respiratory failure, hypertensive heart disease, chronic kidney disease, depression, morbid obesity, post-traumatic stress disorder (PTSD), mood affective disorder, and anemia. Hospital discharge referral dated, for Resident # 63 revealed she was given the medication.

Review of the quarterly MDS assessment for Resident #63, dated 06/19/23, revealed she was cognitively intact. Further review of the MDS assessment revealed she was independent and required no assistance from staff with all activities of daily living.

Review of the Hospital Exemption Notification Screening (HENS) dated 11/28/22 revealed Resident #63 could reside in a skilled nursing facility for a less than thirty day stay or PASARR was completed. Review of PASARR for Resident #63, dated 01/06/23 revealed the facility did complete a PASARR review within the required expiration of the HENS.

3. Record review for Resident #70 revealed he was admitted to the facility on 03/28/23. His diagnoses included dysarthria, dysphagia, intracerebral hemorrhage, essential primary hypertension, bipolar disorder, malingerer, chronic pain syndrome, anxiety disorder, insomnia, hypoglycemia, and psychoactive substance abuse.

Review of the quarterly MDS assessment for Resident #70, dated 07/07/23, revealed he had mildly impaired cognition. Further review of the MDS assessment revealed he required supervision from staff with all activities of daily living.

Review of PASARR, dated 04/17/23 revealed the facility failed to identify Resident # 70's anxiety disorder or bipolar disorder.

Interview on 09/27/23 at 4:29 P.M., with Social Service Designee (SSD) #84 confirmed Resident #24 did not have a Significant Change in Condition PASARR screening completed on 01/11/23. SSD #84 confirmed Resident #63 did not have a PASARR screening completed within thirty days of admission. SSD #84 confirmed the HENS expired on 12/28/22 and the PASARR was not completed until 01/06/23. SSD #84 was unable to provide information regarding the PASARR for Resident #70.

Based on record review, resident interview, staff interview, and policy review, the facility failed to complete a thorough investigation to identify the root cause of the fall during a Hoyer lift transfer. This affected one (#47) of three residents reviewed for falls. The facility census is 83.

Findings include:

Review of Resident #47's medical record revealed an admission date of 05/09/23, with diagnoses including: heart failure, hypertension, Diabetes Mellitus 2, and hyperlipidemia.

Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/15/23, for Resident #47 revealed she was cognitively intact. Further review of the MDS assessment revealed she required extensive assistance from staff with bed mobility, dressing, and personal hygiene. Resident #47 was totally dependent on staff for assistance with transfers and toilet use. Resident # 47 was independent with eating.

Review of nursing progress notes for Resident #47 revealed a nursing note created on 06/21/23 at 7:09 P.M. and effective for 06/21/23 at 11:15 A.M. revealed, the resident stated the Hoyer lift tipped while the aide/s was transferring her to the wheelchair.

Interview on 09/25/23 with Resident #47 revealed she was dropped from a Hoyer lift during a Hoyer lift transfer from her bed to the wheelchair.

Review of the facility form titled, IDT Post Fall/Incident Investigation/Summary, dated 06/21/23 at 11:15 A.M., revealed the Hoyer lift became unbalanced, tipped over and resulted in Resident #47 falling to the floor. The IDT team identified the need for more staff assisting with transfers.

Review of the facility statements obtained from staff revealed the facility failed to obtain a statement from STNA #200 or #201 who were present and attempted to transfer Resident #47 from the wheelchair to the bed on 06/21/23. Review of the statement from Registered Nurse (RN) #49 revealed she was the nurse working on the floor on the day of the incident. RN #49 stated, STNA #200 and #201 informed her the Hoyer lift tilted while they were transferring the resident from the bed to the wheelchair and caused the Resident (#47) to fall on the floor.

Interview on 09/28/23 at 4:24 P.M., with the Director of Nursing (DON) confirmed Resident #47 was dropped from a Hoyer during a transfer on 06/21/23. The DON stated a new Hoyer lift was ordered following the fall. The DON stated she interviewed the two aides involved in the transfer and the previous Hoyer lift was not sturdy enough for Resident #47's weight. The DON stated she thought the previous Hoyer lift held 600 pounds (lbs.) to 800 lbs. However, the DON felt the tip of the Hoyer was related to the distribution of Resident # 47's weight. The DON confirmed she did not feel the issue was related to the need for more staff present, however, she felt the required a Hoyer lift that accommodated a higher weight limit. The DON confirmed the current Hoyer lift has a weight limit of 1000 lbs.

Subsequent interview on 10/02/23 at 3:55 P.M., with Resident #47 confirmed two aides were present during the transfer on 06/21/23. Resident #47 stated the Hoyer left leg was caught on the leg of the bed. Resident #47 confirmed the Hoyer lift tipped and she (Resident #47) fell to the ground. Resident #47 stated she cannot say if it is true or not but one of the aides involved in the Hoyer lift transfer, told her the Hoyer lift used was not sturdy prior to her (Resident #47) incident.

Subsequent interview on 10/02/23 at 11:08 A.M., with the Director of Nursing (DON) confirmed she failed to obtain the statements of the two former STNA (#200, #201) who no longer worked at the facility. The DON stated she had the statements, however, she is no longer able to locate the statements.

Review of the policy titled, Fall and Fall Risk, managing, dated December 2007, revealed the facility will identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling and try to minimize complications from falling.

This deficiency represents noncompliance discovered during complaint investigation of Complaint Numbers OH00146509 and OH00146416.

Based on record review, resident interview, staff interview and observations, revealed the facility failed to ensure pain medications were available and provided timely to a resident to maintain pain management. This affected one (#1) of one resident reviewed for pain management. The facility census was 83.

Findings include:

Review of Resident #1's medical record revealed an admission date of 04/23/07, with diagnoses including age-related osteoporosis and osteoarthritis.

Review of the Minimum Data Set (MDS) assessment dated 07/08/23 revealed Resident #1 was cognitively intact.

Review of physician's orders dated 09/18/23 for Voltaren (diclofenac sodium) gel 1%, apply two grams (g) topically to wrist and arm every day and night shift.

Observation and interview on 09/25/23 at 11:08 A.M., revealed Resident #1 was noted to be shaking her left forearm, wrist, and hand. Resident #1 stated that she had arthritis and it hurt. Resident #1 reported that she told the nurse, and she was given pain medication, but it still hurt.

Interview and observation on 09/25/23 at 3:50 P.M., revealed Resident #1 were shaking her left arm, wrist, and hand. She reported she was still having pain and that her topical analgesic was not available.

Interview on 09/25/23 at 4:06 P.M., with Licensed Practical Nurse (LPN) #23 verified she gave Resident #1 her oral pain medication, but her topical pain medication, Voltaren, was not at the facility and she had to reorder it from the facility.

Interview on 09/27/23 at 8:25 A.M., with LPN #23 stated that Resident #1's Voltaren arrived on 09/26/23.

This deficiency represents noncompliance discovered during complaint investigation of Complaint Numbers OH00146509, OH00146416, and OH00146234.

Based on observations, grievance report review, spread sheet review, email communication review, policy review, resident interviews, staff interviews, Registered Dietician interview, the facility failed to ensure residents were provided with adequate portion sizes and substitutes according to the approved menus/spreadsheets. This had the potential to affect 82 of 82 residents who were served food from the kitchen. The facility identified one resident (#19) did not receive food from the facility kitchen. The facility census was 83.

Findings include:

Review of the facility form titled, Grievance/Complaint Report, dated 07/03/23 revealed Resident #40 stated he was, getting small portions, and would like more protein.

Interview on 09/25/23 at 1:53 P.M., with Resident #7stated the facility only provides small portions of food. Resident #7 stated he will ask for more food and staff will tell them they are out of food. A follow up interview with Resident #07 on 10/02/23 at 3:44 P.M., revealed the facility had an issue in the kitchen over the weekend and was unable to utilize the facility stove. Resident #07 stated he was given three or four bites of oatmeal for breakfast and nothing else on 09/30/23. Resident # 07 stated he was given a hot dog at lunch time on 09/30/23 and nothing else for lunch. Resident #07 stated he was given grilled cheese for dinner with sliced tomatoes on 09/30/23.

Interview on 09/26/23 at 10:45 A.M., with Resident #132 stated the facility served small portions, and they were not served more food if they asked for it.

Observation on 09/27/23 at 11:39 A.M., of the lunch time tray line revealed the facility was serving pulled pork on a burrito shell, topped with shredded cheese, a side of rice, orange slices, and orange drink. Observation of the tray line revealed Dietary Cook (DC) #97 used a set of metal tongs to dip the pulled pork onto the burrito shell, he utilized his gloved hand to dip the shredded cheese garnish and utilized a four-ounce (oz) spoon for the rice.

Review of the facility spread sheet for the lunch meal on 09/27/23 revealed the facility would provide three oz of pork, 1 burrito shell, 1/8 cup of shredded cheese, ½ cup of spanish rice, and ½ cup of oranges.

Interview on 09/27/23 at 11:55 A.M., after the lunch cart had left the kitchen for delivery Dietary Manger (DM) #82 confirmed DC #97 utilized tongs to serve the pulled pork and he should have used a three oz dip. DM #82 confirmed the cook was using a three and half oz spoon, however, he was utilizing a four oz spoon for rice. DM #82 verified the facility ran out of food and was unable to serve the last five residents without cooking more rice.

Observation on 09/27/23 at 4:45 P.M., of the evening tray line revealed the facility served chicken nuggets, green beans, french fries, and cookies for dinner, with orange drink. Observation of the tray line revealed DC #40 used tongs to dip the chicken nuggets onto the resident's plates and utilized his gloved hand to dip the french fries.

Interview at the time of the observation, with DC #40, verified he was utilizing tongs and was using a gloved hand to serve french fries. DC #40 stated he was using a four oz spoon for green beans, and 3 oz spoon for mashed potatoes.

Review of the facility spread sheet for dinner on 09/27/23 revealed the facility would provide the following meal for dinner, chicken nuggets two oz of protein, ½ cup of tater tots, ½ cup of green beans, and frosted white cake (one piece), and a biscuit, and 8 oz of milk.

Review of an email written from the Director of Nursing (DON) to the facility Registered Dietician (RD) #102, dated 09/30/23 at 1:14 P.M., revealed the email stated the facility was unable to utilize the stove related to a gas leak. The email stated, Breakfast today was cereal, served late and didn't match the menu. Lunch today was lunch meat on time and didn't match the menu. Dinner is going to be what was on the menu but cooked on the grill.

Interview on 10/03/23 at 9:20 A.M., with the Registered Dietician (RD) #102 confirmed she was only made aware of the food substitutions listed on the email to the Administrator for Saturday 09/30/23. RD #102 could not confirm if any other items were provided for the meal on 09/30/23. RD #102 stated the facility had already provided breakfast and lunch before an approval of the menu could be given. RD #102 confirmed the facility is supposed to utilize the spreadsheets to determine the amount of food to be given to each resident.

Review of the policy titled, Substitutions, dated April 2007 stated, the Food Service Manager, in conjunction with the Clinical Dietitian, may make food substitutions as appropriate or necessary. Further review of the policy revealed, the Food Service Manager will maintain an exchange list identifying the seven exchanges of food groups.

Review of the policy titled, Kitchen Weights and Measures, dated April 2007, stated, food service staff will be trained in proper use of cooking and serving measurements to maintain portion control. Further review of the policy stated, staff will be trained in the appropriate measurement and type of serving utensil for each food. The Food Service Supervisor will, ensure cooks prepare the appropriate amount of food for the number of servings required.

This deficiency represents noncompliance discovered during complaint investigation of Complaint Numbers OH00146416, OH00146414 and OH00146969.

Based on observation, interview, and policy review, the facility failed to store and prepare food in a safe manner. This had the potential to affect 82 residents who received food from the kitchen. The facility census was 83.

Findings include:

During observation of the kitchen refrigerator on 09/25/23 at 9:21 A.M., there was a plastic container in the refrigerator with sliced cucumbers with no label of the contents, only a date; a block of cheese, opened, with no label or date; a large plastic container of what appeared to be mushrooms with a date, however, no label to confirm what it was; a large bag of peppers with no label or date; a large plastic container of what appeared to be juice located on a shelf in the refrigerator with no label or date. Next to the large container of juice was another large plastic container with a large clump of unknown food inside it. Dietary Manager (DM) #82 stated at the time of the observation it was juice with fruit and that was what was left of the fruit. It did not contain a label or date.

There were two large plastic containers containing flour and sugar in the main kitchen under the counter. The containers did not have a label or a date.

The top of the three compartment sink was soiled with dirt and food crumbs. There was a large cookie sheet pan sitting by the dishwasher with drain flies flying around it. Underneath the dishwasher was black sludge dirt, two plastic lids, food crumbs, and dirt. There were broken tiles behind the stove.

Observation of the dry storage area revealed a bag of moldy hot dog buns.

During interview on 09/27/23 at 11:35 A.M. DM #82 confirmed the above observations.

During observation on 09/27/23 at 11:39 A.M., a yellow substance was rolling around underneath several clean trays as they were loaded onto the lunch cart. The tray line was stopped and Dietary Cook (DC) #97 stated the yellow substance was eggs from breakfast all along the tray prep top area. DC #97 utilized his gloved hands to garnish burritos with cheese instead of using a utensil. The tray line rand out of plates and silverware during lunch service. DM #82 took dirty dishes and silverware from the first tray cart and washed them to have enough dishware to complete lunch service. DM #82 confirmed the facility did not have enough silverware and dishes to serve all the residents.

During observation on 09/27/23 at 4:45 P.M. (DC) #40 utilized his gloved hand to serve french fries. DC #40 took dirty dishes from the dirty food cart returned to the kitchen and washed them to have enough dishware to serve all residents dinner. DC #40 confirmed the facility did not have enough silverware and dishes to complete the tray line.

During observation on 09/28/23 at 3:40 P.M., the sludge, dirt, and debris all over the floor and trash under dish machine, sink, and stove remained. This was confirmed by DM #82.

Review of the document from the pest control company visit, dated 07/10/23, stated, roaches in the broken tile behind the ovens in the kitchen, this still needs repaired. The document dated 08/14/23 revealed Kitchen has very poor sanitation. Please focus on keeping the dishwasher area clean please. Notes-Please focus on keeping the dishwasher area clean.

Review of the State of Ohio county health department, Food Inspection Report, dated 08/15/23, revealed, observed the presence of roaches under the stove of the facility, and it is not being adequately controlled. Observed the top of the dish washing machine soiled in debris. The reporter stated the floors in the kitchen are not cleaned as often as necessary. Observed fruit flies and vegetables in the walk-in refrigerator.

Review of the facility policy titled, Food Receiving and Storage, dated October 2017, stated, Foods shall be received and stored in a manner that complies with safe food handling practices. All food stored in the refrigerator or freezer will be covered, labeled, and dated.

Based on observation, staff interview, and policy review, the facility failed to provide a home like environment by maintaining shower rooms and ensuring there was enough plates and silverware to serve meals. This had the potential to affect up to 50 of 83 residents who reside in the faciltiy. Excluding Resident #19, who does not receive food and a total of 59 residents who do not utilize the shower rooms. The facility census was 83.

Findings include:

1. Observation on 09/26/23 at 9:24 A.M., of the shower room located by the central services room revealed the air vents contained large amounts of fuzzy dust and dirt hanging off them in a fringe- like manner. The shower room contained black sludge like substances around the bottom of the shower room walls and on the floor of the shower room. The shower room had busted tile with exposed wall.

Interview on 09/26/23 at 9:24 A.M., with State Tested Nurse Aide (STNA) #83 confirmed the air vents in the shower room located near the central supply room had fuzzy, dust and dirt hanging off the vents. STNA #83 confirmed the shower contained a black sludge like substance around the bottom of the shower room and on the floor of the shower room. STNA #83 confirmed the shower room had busted tiles and exposed wall.

Observation 09/28/23 at 11:13 A.M., revealed the East Shower room contained a fuzzy dirt substance hanging from the shower vents. The around the bottom of the walls and flooring in the shower contained a black sludge and a black substance with fuzz around it. The shower tile was chipped, and caulking was exposed.

Interview on 09/28/23 at 11:13 A.M., with Licensed Practical Nurse (LPN) #24 confirmed the East Shower room contained dirt and long fuzzy dust hanging from the shower vent. LPN #24 stated, that black fuzzy stuff around the bottom of the walls and flooring of the shower is mold. LPN #24 confirmed the tiles were chipped and caulking exposed.

2. Observation on 09/27/23 at 11:35 A.M., of the tray line for lunch revealed the facility did not have enough plates and silverware to complete the tray line. Observations revealed the Dietary Manager (DM) #82 pulled plates from the first hall soiled cart, that had just returned from being delivered and returned to the kitchen. DM #82 then proceeded to run the plates and silverware through the dishwasher and then utilize the dishes and silverware, for the last hall cart to go out for lunch, to ensure enough dishes and silverware were available for all residents.

Interview on 09/27/23 at 12:40 P.M., with DM#82 confirmed the facility does not have enough plates or silverware to serve each resident at every meal without washing items from the first soiled returned dining cart.

Observation on 09/27/23 at 5:25 P.M., of the dinner meal revealed the facility was unable to complete the tray line without washing ten trays from the first soiled hall cart returned.

Interview on 09/27/23 at 5:29 P.M., with the DM #82 confirmed the facility does not have enough plates or silverware to complete the trays for dinner without washing the soiled items from first hall cart that goes out. DM #82 stated the facility should complete a facility sweep of resident rooms to see if there are trays and silverware that have not been returned because the residents will eat meals in their room.

Review of the policy titled, Quality of Life-Homelike Environment, dated May 2017 stated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Further review of the policy revealed the facility and staff shall maximize the characteristics of the facility to reflect a homelike setting including a clean, sanitary, and orderly environment. The policy stated, staff shall provide person-centered care that emphasizes the resident's comfort, independence, and personal needs and preferences.

This deficiency represents noncompliance discovered during complaint investigation of Complaint Numbers OH00146517, OH00146416, OH00146414, and OH00146234.

Based on observation, interview and policy review, the facility failed to ensure the facility was free of gnats. This affected the kitchen area. The facility census was 83.

Findings include:

During observation during the initial tour of the facility kitchen on 09/25/23 at 9:21 A.M., a large, soiled cookie sheet pan had drain flies flying around the pan.

During interview at the time of the observation, Dietary Manager (DM) #82 confirmed the facility has an issue with gnats in the drain.

Review of the pest control billing statements revealed the facility had been treated for gnats on 08/14/23. The statement stated the Kitchen has very poor sanitation. Please focus on keeping the dishwasher area clean please.

Review of the policy titled Pest Control, dated May 2008, stated, the facility shall maintain an effective pest control program and the building is kept free of insects and rodents.

This deficiency represents noncompliance discovered during complaint investigation of Complaint Number OH00146416.

Based on record review, observations, staff interviews, review of facility policy, and review of online guidance per the Centers for Disease Control (CDC), the facility failed to ensure staff wore proper personal protective equipment (PPE) to prevent the spread of Coronavirus Disease 2019 (COVID-19). This affected four (#39, #58, #61 and #80) of five residents reviewed for infection control. The facility census was 81.

Findings include:

1. Review of the medical record for Resident #39 revealed an admission date of 09/25/20 with diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure (CRF) with hypoxia, diabetes mellitus (DM), anxiety disorder, cerebral infarction, and atherosclerotic heart disease.

Review of the Minimum Data Set (MDS) for Resident #39 dated 08/11/23 revealed resident was cognitively intact and required limited assistance of one staff with activities of daily living (ADL's).

Review of the physician orders for Resident #39 revealed an order dated 09/08/23 for strict room isolation with all services provided in the room due to positive COVID-19 infection.

Interview on 09/08/23 at 9:26 A.M. during the entrance conference of Licensed Practical Nurse (LPN) #325 confirmed the facility was experiencing a COVID-19 outbreak with 23 COVID-19 positive residents in the facility at the time of the survey. LPN #325 confirmed staff should don the following personal equipment when entering the room or working with a COVID positive resident: gown, gloves, N-95 mask, eye protection (face shield)

Observation on 09/08/23 at 9:42 A.M. revealed Resident #39's door was shut and there was a sign on the door indicating the resident was on droplet precautions and there was an isolation cart outside the door. Further observation revealed LPN #585 entered Resident #39's room wearing a cloth mask and carrying a plastic cup of pills and a cup of water.

Observation on 09/08/23 at 9:48 A.M. revealed LPN #585 exited the room wearing a cloth mask.

Interview on 09/08/23 at 9:48 A.M. of LPN #585 confirmed she was an agency nurse and no one had told her in report that Resident #39 had COVID-19. LPN #585 confirmed she was wearing a cloth mask she brought from home and had not donned PPE prior to entering Resident's #39's room to administer medications.

2. Review of the medical record for Resident #80 revealed an admission date of 06/13/23 with diagnoses including cerebral infarction, DM, and atrial fibrillation.

Review of the MDS for Resident #80 dated 08/17/23 revealed resident was cognitively intact and required limited assistance of one staff with ADL's.

Review of the physician orders for Resident #80 revealed an order dated 09/06/23 for strict room isolation with all services provided in the room due to positive COVID-19 infection.

Interview on 09/08/23 at 10:25 A.M. with the Director of Nursing (DON), the Infection Preventionist (IP) for the facility confirmed staff should wear an N-95 mask when providing care to a COVID-19 positive resident.

Observation on 09/08/23 at 12:09 P.M. revealed Resident #80's door was shut and there was a sign on the door indicating resident was on droplet precautions and there was an isolation cart outside the door. Further observation revealed State Tested Nursing Assistant (STNA) #350 entered Resident #80's room carrying a lunch tray. Prior to entering the room STNA #350 donned gown, glove, surgical mask and face shield.

Interview on 09/08/23 at 12:16 P.M. of STNA #350 confirmed she entered Resident #80's room to deliver his lunch tray and to provide care wearing a gown, gloves, surgical mask and face shield. STNA #350 confirmed Resident #80 was COVID-19 positive. STNA #350 thought wearing an N-95 mask was optional and that a surgical mask was an acceptable substitute.

3. Review of the medical record for Resident #61 revealed an admission date of 06/01/23 with diagnoses including, anxiety disorder, cerebral infarction, depression, hypertension, and DM.

Review of the MDS for Resident #61 dated 07/29/23 revealed resident was cognitively intact and required limited assistance with ADL's.

Review of the physician orders for Resident #61 revealed an order dated 09/04/23 for strict room isolation with all services provided in the room due to positive COVID-19 infection.

Observation on 09/08/23 at 12:19 P.M. revealed Physical Therapist (PT) #510 was providing stand by assistance with ambulation to Resident #61 in the hallway. Resident #61 was wearing a surgical mask and was walking toward the exit. PT #510 was wearing a surgical mask with an N-95 mask on top of the surgical mask.

Interview on 09/08/23 at 12:19 P.M. of PT #510 confirmed Resident #61 was COVID-19 positive and he was assisting the resident to go outside to get some fresh air. PT #510 confirmed he was wearing an N-95 mask on top of a surgical mask.

Interview on 09/08/23 at 1:50 P.M. with the DON confirmed an N-95 mask should not be placed on top of a surgical mask because this practice defeats the purpose of the N-95 and does not allow the N-95 to seal properly thus increasing the risk of transmission of infection.

4. Review of the medical record for Resident #58 revealed an admission date of 07/07/22 with diagnoses including seizures, insomnia, mood disorder, hypertension, and hemiplegia and hemiparesis following cerebral infarction.

Review of the MDS for Resident #58 dated 06/14/23 revealed resident was cognitively intact and required supervision of one staff with ADL's.

Review of the physician orders for Resident #58 revealed an order dated 09/04/23 for strict room isolation with all services provided in the room due to positive COVID-19 infection.

Observation on 09/08/23 at 12:10 P.M. revealed Resident #58's door was shut and there was a sign on the door indicating resident was on droplet precautions and there was an isolation cart outside the door. Further observation revealed STNA #210 entered Resident 58's room carrying a lunch tray. Prior to entering the room STNA #210 donned gown, gloves, and surgical mask.

Interview on 09/08/23 at 12:23 P.M. of STNA #210 confirmed Resident #58 was COVID-19 positive and she had entered his room to deliver his meal tray and provide care wearing a gown, gloves, and a surgical mask. STNA #210 confirmed eye protection was available, but she had donned a face shield before entering Resident #58's room.

Interview on 09/08/23 at 1:50 P.M. with the DON confirmed the facility had an adequate supply of PPE including N-95 masks and face shields.

Review of information handout per the CDC undated and provided to the staff as part of the facility's infection control education titled Sequence for Donning PPE revealed staff should ensure mask/respirator fits snugly against the face.

Review of the facility Droplet Precautions sign undated which had been placed on the doors of rooms for Residents #39, #58, #61, and #80 revealed the sign indicated staff should ensure their eyes, mouth, and nose were fully covered prior to entering the room.

Review of the facility policy titled Personal Protective Equipment (PPE) dated January 2012 revealed employees who failed to use appropriate PPE when indicated could be subject to disciplinary action.

Review of online resource per the CDC at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 05/08/23 revealed healthcare workers who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH Approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).

This deficiency represents non-compliance investigated under Complaint Number OH00146145.

Based on observation, medical record review, and staff interview, the facility failed to ensure medications were administered as ordered by the physician. A total of three medication errors were observed out of 25 opportunities for a medication error rate of 12 percent (%). This affected two (#60 and #61) of four residents observed during medication administration. The facility census was 82.

Findings include:

1. Review of Resident #60's medical record revealed an admission date of 01/06/23 with diagnoses including hemiplegia and hemiparesis following cerebral infarction, type two diabetes mellitus, and hypertension.

Review of a physician order dated 02/16/23 revealed Resident #60 was ordered supplement vitamin D2 50,000 units one capsule by mouth once daily on Monday and Thursday for vitamin D deficiency.

Observation on Thursday, 06/22/23 at 8:10 A.M., revealed Registered Nurse (RN) #125 administered medications to Resident #60 including one capsule of supplemental cholecalciferol (Vitamin D3) 1,000 units.

Interview with RN #125 on 06/22/23 at 10:09 A.M. verified Resident #60 had orders to receive vitamin D2 50,000 units, but was administered vitamin D3 1,000 units in error.

2. Review of Resident #61's medical record revealed an admission date of 05/05/22 with diagnoses including chronic obstructive pulmonary disease, schizophrenia, depression, and type two diabetes mellitus.

Review of a physician order dated 11/21/22 revealed Resident #61 was ordered an anti-seizure medication Depakote 500 milligrams (mg) by mouth once daily for seizures.

Review of a physician order dated 11/21/22 revealed an order for cholecalciferol (Vitamin D3) 4,000 units once daily.

Observation on 06/22/23 at 8:16 A.M. revealed RN #125 administered medications to Resident #61 including one tablet of Depakote 250 mg and two tablets of vitamin D3 1,000 units.

Interview with RN #125 on 06/22/23 at 10:10 A.M. verified Resident #61 had orders for Depakote 500 mg and vitamin D3 4,000 units, but was administered one tablet of Depakote 250 mg and two tablets of vitamin D3 1,000 units.

This deficiency represents non-compliance investigated under Complaint Number OH00142819.

Based on medical record review, staff interviews, and policy review, the facility failed to ensure wound care orders were completed as ordered. This affected one resident (#76) out of three residents reviewed for wound care. The facility census was 77.

Findings include:

Review of the medical record for Resident #76 revealed Resident #76 was admitted to the facility on 03/07/23 and transferred to the hospital on 03/25/23 at the request of Resident #76's family. Diagnoses included congestive heart failure, type two diabetes mellitus without complications, hypertensive heart disease with heart failure, and hyperlipidemia.

Review of Resident #76's admission Minimum Data Set (MDS) 3.0 assessment, dated 03/13/23, revealed Resident #76 had severely impaired cognition. Resident #76 was assessed to require extensive assistance for bed mobility, transfer, dressing, eating, and personal hygiene, and was totally dependent for toilet use. The assessment indicated Resident #76 was at risk for developing pressure ulcers with no pressure ulcers noted.

Review of the facility assessment titled Braden Scale for Predicting Pressure Sore Risk

Based on record review, observation, resident and staff interviews, and review of facility policy, the facility failed to ensure a clean, comfortable, and homelike environment in resident rooms. This affected two (#43 and #63) of three residents reviewed for physical environment. The facility census was 81.

Findings include:

1. Review of the medical record for Resident #43 revealed an admission date of 01/25/23 with diagnoses including paraplegia, neuromuscular dysfunction of bladder, hypertension, diabetes mellitus, and chronic pain syndrome.

Review of the Minimum Data Set (MDS) for Resident #43 dated 01/31/23 revealed the resident was cognitively intact and required extensive assistance of two staff with activities of daily living (ADL's).

Observation on 03/07/23 at 4:00 P.M. of Resident #43's room revealed there was a hole in the resident's wall which connected with the outside of the building. The hole was approximately one inch in diameter and was observed just above the upper right hand corner of the wall air conditioning unit. Sunlight from outside was observed shining through the hole and cold air could be felt coming through the hole.

Interview on 03/07/23 at 4:00 P.M. with Resident #43 confirmed the hole had been there for a while, a couple months. Resident #43 confirmed on a warm day he had ants crawl into his room through the hole and he had notified the staff but he couldn't remember who he told.

Interview on 03/07/23 at 4:21 P.M. with Maintenance Director (MD) #150 confirmed there was a hole in Resident #43's wall. MD #150 confirmed he was not aware of the hole until the surveyor brought it to his attention. MD #150 confirmed the hole should be repaired as it did not contribute to a homelike environment and could allow bugs/pests and/or the elements to get inside the resident's room.

2. Review of the medical record for Resident #63 revealed an admission date of 05/09/21 with diagnoses including schizoaffective disorder, head injury, blindness to right eye, and depression.

Review of the MDS for Resident #63 dated 01/11/23 revealed the resident was cognitively intact and required extensive assistance of one to two staff with ADL's.

Observation on 03/08/23 at 8:45 A.M. of Resident #63's room revealed the floor was dirty with a black residue scattered across the floor.

Interview on 03/08/23 at 8:45 A.M. of Resident #63 confirmed his floor had not mopped in a few days and the debris on the floor was because he eats in his room. Resident #63 confirmed he would prefer to have his room mopped daily.

Interview on 03/08/23 at 8:46 A.M. with State Tested Nursing Assistant (STNA) #350 confirmed Resident #63's floor was dirty and she thought the debris on the floor was related to spilled food and drinks.

Interview on 03/08/23 at 9:45 A.M. with Housekeeper #375 confirmed resident floors should be mopped daily. Housekeeper #375 confirmed Resident #63's floor was dirty and looked as if it had not been mopped for several days. Housekeeper #375 confirmed she had not worked on Resident #63's side of the building so she was unsure when it had last been mopped. Housekeeper #375 confirmed it looked like the floor was dirty from spilled food, beverages and nutritional supplements.

Review of the facility policy titled Floors dated December 2009 revealed floors shall be maintained in a clean, safe, and sanitary manner. All floors shall be mopped/cleaned/vacuumed daily in accordance with established procedures.

This deficiency represents non-compliance investigated under Complaint Number OH00140310.

Based on record review, observation, resident nd staff interview, and review of facility policies, the facility failed to ensure safe and proper storage of medications. This affected one (#43) of three residents reviewed for physical environment. The facility census was 81.

Findings include:

Review of the medical record for Resident #43 revealed an admission date of 01/25/23 with diagnoses including paraplegia, neuromuscular dysfunction of bladder, hypertension, diabetes mellitus, and chronic pain syndrome.

Review of the Minimum Data Set (MDS) for Resident #43 dated 01/31/23 revealed the resident was cognitively intact and required extensive assistance of two staff with activities of daily living (ADL's).

Review of the March 2023 monthly physician orders for Resident #43 revealed an order dated 01/26/23 for Colace 100 milligrams (mg) twice daily.

Review of the March 2023 Medication Administration Record (MAR) for Resident #43 revealed 5:00 P.M. dose of Colace was signed off on 03/07/23 as administered by Licensed Practical Nurse (LPN) #100.

Further review of Resident #43's medical record revealed there was no information such as an assessment and/or order regarding the self-administration of medications.

Observation on 03/07/23 at 4:03 P.M. revealed there was a white round tablet in a plastic cup at Resident #43's bedside.

Interview on 03/07/23 at 4:03 P.M. with Resident #43 confirmed Licensed Practical Nurse (LPN) #100 brought his 5:00 P.M. dose of Colace into his room and left it at his bedside because he was receiving care.

Interview on 03/07/23 at 4:04 P.M. with LPN #125, the Unit Manager, confirmed there was a pill at Resident #43's bedside. LPN #125 confirmed Resident #43 did not have an order to self-administer medications or to leave medications at the bedside.

Interview on 03/07/23 at 4:04 P.M. with LPN #100 confirmed she was an agency nurse and she went to give Resident #43 his 5:00 P.M. dose of Colace but he was receiving care per the aides so she left the medication at his bedside. LPN #100 confirmed she did not see any orders for resident to self-administer medications or to leave medications at the bedside.

Interview on 03/07/23 at 4:25 P.M. with the Administrator confirmed Resident #43 did not have an order to self-administer medications. Administrator confirmed medications should not be left at the bedside.

Review of the facility policy titled Administering Medications dated April 2019 revealed if a resident is unavailable to receive medication the nurse will return to missed resident to administer the medication.

Review of the facility policy titled Storage of Medications dated April 2019 revealed all drugs and biological's are stored in locked compartments and the facility stores all drugs and biological's in a safe secure and orderly manner.

This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review, observations, staff interviews, review of facility work orders, and review of the facility policy, the facility failed to ensure resident call lights were functional. This affected two (#21 and #22) of three residents reviewed for physical environment. The facility census was 81.

Findings include:

1. Review of the medical record for Resident #21 revealed an admission date of 06/01/22 with diagnoses of acute osteomyelitis, acute respiratory failure with hypoxia, congestive heart failure (CHF), dementia with behavioral disturbance, anemia, hypertension, peripheral vascular disease, and dysphagia.

Review of the Minimum Data Set (MDS) for Resident #21 dated 12/31/22 revealed the resident was cognitively impaired and was totally dependent on the assistance of one staff with bed mobility and transfers.

Review of the care plan for Resident #21 dated 10/17/22 revealed the resident was at increased risk for falls and fall related injuries related to deconditioning, confusion, gait/balance problems, incontinence, behaviors of putting self on floor beside bed, non-compliance, weakness, and impaired memory. Interventions included be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.

2. Review of the medical record for Resident #22 revealed an admission date of 01/11/23 with diagnoses including generalized anxiety disorder, multiple rib fractures, chronic obstructive pulmonary disease (COPD), acute respiratory failure, alcoholic cirrhosis of the liver, ascites, hypertension, atrial fibrillation and hepatitis.

Review of the MDS for Resident #22 dated 02/02/23 revealed the resident was cognitively intact and required extensive assistance of two staff with bed mobility and transfer.

Review of the care plan for Resident #22 dated 01/30/23 revealed the resident was at high risk for falls related to poor decision making and non-compliance with calling for assistance. Interventions included be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.

Observation on 03/07/23 at 4:12 P.M. revealed the wall panel for the call lights in the room shared by Residents #21 and #22 had been ripped out of the wall and was dangling in air. There were no call light cords for Residents #21 and #22 to use to summon assistance via the facility's call light system. Resident #21 did not respond to request for interview and Resident #22 was sleeping.

Interview on 03/07/23 at 4:15 P.M. with Licensed Practical Nurse (LPN) #175 confirmed she was an agency nurse and had been working in the building since 7:00 A.M. that morning. LPN #175 confirmed she was unaware Resident #21 and #22's call lights were not in place and functioning.

Interview on 03/07/23 at 4:17 P.M. with State Tested Nursing Assistant (STNA) #200 confirmed she was the aide for Residents #21 and #22 and the call light panel on the wall had been ripped off for at a least a month. STNA #200 confirmed the facility knew the call lights were not working and the resident's did not have a way to call for assistance so she tried to check on them more frequently.

Interview on 03/07/23 at 4:24 P.M. with Maintenance Director (MD) #150 confirmed the call light in Resident #21 and #22's room had a short in it and needs to be replaced. MD #150 confirmed he pulled the panel out of the wall while trying to assess the problem, and that the call light in the room had been out of service for about a week. MD #150 confirmed Residents #21 and #22 were provided with bells to use to summon assistance until it could be repaired.

Observation on 03/07/23 at 4:24 P.M. with MD #150 and Administrator revealed Residents #21 and #22 had small bicycle style bells but neither resident had the bell within their reach.

Interview on 03/07/23 at 4:25 P.M. with the Administrator confirmed both Resident #21 and #22 were capable of using a call light/bell but neither resident was able to get out of bed to retrieve the call bell. Administrator confirmed call bells should be in reach.

Review of the facility work orders for 02/08/23 to 03/08/23 revealed a work order dated 02/27/23 which indicated Resident #21 and #22's call light needed to replaced. The work order had not been completed.

Review of the facility policy titled Answering the Call Light dated October 2010 revealed staff should be sure that the call light was plugged in at all times and when the resident is in bed or confined to a chair staff should be sure the call light is within easy reach of the resident. Staff should report all defective call lights to the nurse supervisor promptly.

This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record reviews, observations, staff interviews, and policy reviews, the facility failed to discard/destroy controlled medications in a timely manner and failed to remove expired medications from medication carts. This affected six of six medication carts observed for medication storage. The facility had a total of six medication carts. This affected ten residents (#10, #11, #12, #13, #14, #15, #16, #17, #18, and #19). The facility census was 80.

Findings include:

1. Record review for Resident #10 revealed Resident #10 was admitted on 09/05/18. Diagnoses included lung cancer, anxiety, peripheral vascular disease, spinal stenosis, chronic pain. Review of Resident #10's physician orders dated 07/27/22 revealed an order to discontinue Ativan (anti-anxiety) one milligram (mg). On 07/28/22, there was an order to discontinue hydromorphone (narcotic pain medication) two mg.

An observation on 08/09/22 at 10:48 A.M. with Licensed Practical Nurse (LPN) #96 of the front east medication cart revealed the discontinued medications of Ativan one and hydromorphone two mg discontinued remained in the medication cart for Resident #10.

2. Record review for Resident #18 revealed Resident #18 was admitted on 12/23/19. Diagnoses included COVID-19, dementia, congestive heart failure, chronic kidney failure, and pulmonary nodule. Review of Resident #18's physician's orders dated 06/28/22 revealed an order to discontinue Percocet (narcotic pain medication) five mg/325 mg.

Record review for Resident #19 revealed Resident #19 was admitted on 07/23/15. Diagnoses included pneumonia, vascular dementia, anxiety, and cerebral infarction. Review of Resident #19's physician's order dated 06/20/22 revealed an order to discontinue Ambien five mg,

Observation and interview on 08/09/22 at 10:04 A.M. with Licensed Practical Nurse (LPN) #70 of east back medication cart revealed Resident #19's discontinued controlled medications Ambien five mg milligrams and tramadol 50 mg remained in the medication cart despite the medications being discontinued. Resident #18's discontinued controlled medications Percocet five mg/325 mg remained in the medication cart despite the medications being discontinued. LPN #70 verified the narcotic medications for Residents #18 and #19 remained in the medication cart and verified they should have been removed from the narcotic box inside the medication cart.

3. Record review for Resident #16 revealed Resident #16 was admitted on 07/07/17. Diagnoses included dementia, panic disorder, depression, psychotic disorder, and Bell's palsy. Review of Resident #16's physician's order dated 07/07/22 revealed an order to discontinue Ambien (sleep aid) five mg.

Record review for Resident #17 revealed Resident #17 was admitted on 04/27/22. Diagnoses included neuropathy, dementia, anxiety, dysphonia, depression, scoliosis, and pneumonia. Resident #17 discharged from the facility on 07/15/22.

Observation on 08/09/22 at 10:15 A.M. with LPN #97 of the west back medication cart revealed a bottle of multivitamin with expiration date of 05/2022, one bottle of folic acid with expiration date of 06/2022, and lyrica (narcotic for pain) 150 mg. Resident #17's hydrodone five mg/325 mg remained in the medication cart despite Resident #17 being discharged from the facility on 07/15/22.

Observation 08/09/22 at 10:22 A.M. with LPN #97 of the short back medication cart revealed a bottle of folic acid with the expiration date of 05/2022. Resident #16's Ambien five mg remained in the medication cart despite Resident #16's Ambien being discontinued on 07/07/22.

An interview on 08/09/22 at 10:25 A.M. with LPN #97 verified the expired medications should have been removed from the medication card and the narcotic medications for Residents #16 and #17 should have been removed from the narcotic box inside the medication cart.

4. Record review for Resident #13 revealed Resident #13 was admitted on 07/13/21. Diagnoses included encephalopathy, hepatitis C, anxiety, depression, insomnia, and bipolar. Review of Resident #13's physician's order dated 07/13/22 revealed on order to discontinue hydrocodone (narcotic pain medication) five mg/325 mg. There was an order dated 07/26/22 to discontinue oxycodone (narcotic) 10 mg.

Record review for Resident #14 revealed Resident #14 was admitted on 07/28/21. Diagnoses included heart failure, diabetes mellitus, peripheral vascular disease, benign intracranial hypertension, chronic ischemic heart disease, and rheumatoid arthritis. Resident #14 discharged from the facility on 07/08/22.

Record review for Resident #15 revealed Resident #15 was admitted on 06/23/22. Diagnoses included acute respiratory failure, congestive heart failure, atrial fibrillation, depression, anxiety, myocardial infarction, and morbid obesity. Resident #15 was discharged from the facility on 07/12/22.

Observations on 08/09/22 at 10:35 A.M. with LPN #96 of the front west medication cart revealed the discontinued medications remained in the medication cart. Resident #15's Tramadol which was discontinued on 07/12/22, Resident #14's Ativan which was discontinued on 07/08/22, and Resident #13's hydrocodone and oxycodone which was discontinued on 07/13/22 and 07/26/22 respectively all remained in the narcotic box inside the medication cart.

An interview on 08/09/22 at 10:50 A.M. with LPN #96 verified the expired medications and the narcotic medications for Residents 13, #14, and #15 should have been removed from the narcotic box. LPN #96 reported that she had told administration that the narcotics medications needed to be removed from the medication carts.

5. Record review for Resident #11 revealed Resident #11 was admitted on 05/17/22. Diagnoses included metabolic encephalopathy, acute kidney failure, interstitial cystitis, bipolar disorder, depression, post-traumatic stress disorder, Crohn's disease, anxiety, and schizoaffective disorder. Resident #11 discharged from the facility on 07/01/22.

Record review for Resident #12 revealed Resident #12 was admitted on 07/15/22. Diagnoses included respiratory failure, congestive heart failure, diabetes mellitus, anemia, morbid obesity, hypertension, anxiety, and metabolic syndrome. Resident #12 discharged from the facility on 07/15/22.

An observation on 08/09/22 at 10:40 A.M. with LPN #96 of the short front medication cart revealed a bottle of multivitamins with expiration date of 05/2022, a bottle of fiber-lax with expiration date 07/2022. Resident #11's hydrodone five mg/325 mg remained in the medication cart despite Resident #11 being discharged from the facility on 07/01/22. Resident #12's oxycodone five mg remained in the medication cart despite Resident #12 being discharged from the facility on 07/15/22.

An interview on 08/09/22 at 10:50 A.M. with LPN #96 verified the expired medications and the narcotic medications for Residents #12 and #13 should have been removed from the narcotic box. LPN #96 reported she had told administration that the narcotics medications needed to be removed from the medication carts.

Review of the facility's policy titled Discarding and Destroying Medications Policy