Lincoln Crawford Care Center

Based on record review, staff interview, and policy review, the facility failed to accurately complete an updated pre-admission screening and resident review (PASARR) for residents with a diagnosis change. This affected one (#27) of three residents reviewed for PASARR. The facility census was 83.

Findings include:

1. Review of the medical record for Resident #27 revealed an admission date of 08/05/19. Diagnoses included progressive multifocal leukoencephalopathy (PML), parkinson's disease, major depressive disorder, bipolar disorder, anxiety disorder, and schizoaffective disorder.

Review of the Quarterly Minimum Data Set (MDS) assessment dated 02/09/24 revealed Resident #27 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. This resident was assessed to require supervision with toileting and transfers, and partial assistance with bathing and dressing.

Review of the physician order dated 03/15/24 revealed Resident #27 was ordered Risperdal 0.5 milligrams (mg), give one tablet by mouth two times a day for depression.

Review of the physician order dated 03/15/24 revealed Resident #27 was ordered Zoloft 50 mg, give one tablet by mouth one time a day for depression.

Review of the PASARR dated 09/04/19 for Resident #27 was the most current PASARR. The PASARR was not updated after new mental health diagnoses.

Interview on 03/20/24 at 3:39 P.M., with the Administrator verified Resident #27's PASARR was not updated after a diagnosis change.

Review of the policy titled, Admissions - From Other Healthcare Facilities

Based on review of the medical record, staff interviews, and policy review, the facility failed to complete care conferences as required. This affected two residents (#27 and #58) of 24 residents reviewed. The facility census was 83. Findings include: 1. Review of the medical record for Resident #27 revealed an admission date of 08/05/19. Diagnoses included progressive multifocal leukoencephalopathy (PML), parkinson's disease, major depressive disorder, bipolar disorder, anxiety disorder, and schizoaffective disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated 02/09/24 revealed Resident #27 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. This resident was assessed to require supervision with toileting and transfers, and partial assistance with bathing and dressing. Review of the medical record for Resident #27 revealed a care conference had been completed on 07/12/23, 01/04/24, and 02/28/24 for the last 12 months. Interview on 03/21/24 at 10:44 A.M., with Social Services Director (SSD) #23 verified Resident #27 did not have regular quarterly care conferences for the last 12 months. 2. Review of the medical record for Resident #58 revealed an admission date of 01/29/21. Diagnoses included sepsis, hypertension, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of the Quarterly Minimum Data Set (MDS) assessment dated 02/27/24 revealed Resident #58 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of eight. This resident was assessed to require setup for eating, supervision with toileting and dressing, substantial assistance with bathing, and partial assistance with transfers. Review of the medical record for Resident #58 revealed a care conference had been completed on 09/25/23, 02/09/24, and 02/24/24 for the last 12 months. Interview on 03/21/24 at 10:39 A.M. with SSD #23 verified Resident #58 did not have regular quarterly care conferences for the last 12 months. Review of the policy titled, Care Planning - Interdisciplinary TeamBased on review of the medical record, staff interviews, and policy review, the facility failed to complete care conferences as required. This affected two residents (#27 and #58) of 24 residents reviewed. The facility census was 83.

Findings include:

1. Review of the medical record for Resident #27 revealed an admission date of 08/05/19. Diagnoses included progressive multifocal leukoencephalopathy (PML), parkinson's disease, major depressive disorder, bipolar disorder, anxiety disorder, and schizoaffective disorder.

Review of the Quarterly Minimum Data Set (MDS) assessment dated 02/09/24 revealed Resident #27 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. This resident was assessed to require supervision with toileting and transfers, and partial assistance with bathing and dressing.

Review of the medical record for Resident #27 revealed a care conference had been completed on 07/12/23, 01/04/24, and 02/28/24 for the last 12 months.

Interview on 03/21/24 at 10:44 A.M., with Social Services Director (SSD) #23 verified Resident #27 did not have regular quarterly care conferences for the last 12 months.

2. Review of the medical record for Resident #58 revealed an admission date of 01/29/21. Diagnoses included sepsis, hypertension, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.

Review of the Quarterly Minimum Data Set (MDS) assessment dated 02/27/24 revealed Resident #58 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of eight. This resident was assessed to require setup for eating, supervision with toileting and dressing, substantial assistance with bathing, and partial assistance with transfers.

Review of the medical record for Resident #58 revealed a care conference had been completed on 09/25/23, 02/09/24, and 02/24/24 for the last 12 months.

Interview on 03/21/24 at 10:39 A.M. with SSD #23 verified Resident #58 did not have regular quarterly care conferences for the last 12 months.

Review of the policy titled, Care Planning - Interdisciplinary Team

Based on observations, medical record review, staff interviews, and policy review, the facility failed to ensure a safe, clean, and home-like environment. This affected two (#2 and #27) of 24 residents reviewed for environment. The facility census was 83. Findings include: 1. Review of the medical record for Resident #2 revealed she was admitted to the facility on 04/13/18. Diagnoses included type two diabetes mellitus with other diabetic kidney complication, other sequelae of cerebral infarction, chronic kidney disease stage three, schizophrenia, morbid obesity due to excess calories, major depressive disorder, neuromuscular dysfunction of bladder, chronic obstructive pulmonary disease, cerebral ischemia, hyperlipidemia, and dysphagia following cerebral infarction. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/11/24, revealed this resident had severely impaired cognition. This resident was assessed to require moderate assistance with eating and oral hygiene, maximal assistance with bed mobility, and was dependent on staff for dressing, personal hygiene, transfer, toileting, and bathing. Observation on 03/21/24 at 11:50 A.M., revealed there was a vertical gash with missing drywall and chipped paint in the wall near the baseboard behind the head of Resident #2's bed, which was visible when standing next to the bed. Interview on 03/21/24 at 12:00 P.M., with Licensed Practical Nurse (LPN) #11 confirmed the gash in the wall in Resident #2's room. 2. Review of the medical record for Resident #27 revealed an admission date of 08/05/19. Diagnoses included progressive multifocal leukoencephalopathy (PML), parkinson's disease, major depressive disorder, bipolar disorder, anxiety disorder, and schizoaffective disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated 02/09/24 revealed Resident #27 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. This resident was assessed to require supervision with toileting and transfers, and partial assistance with bathing and dressing. Observations throughout the annual survey (03/18/24 - 03/21/24) revealed Resident #27's bed sheets had scattered brown substance at the head of the bed. Observations throughout the annual survey (03/18/24 - 03/21/24) revealed Resident #27's wall behind her bed had scattered brownish-orange substance on the wall and the overhead light. The substance was scattered from the head of the bed to the foot of the bed. Interview on 03/21/24 at 11:44 A.M., with State Tested Nurses Aide (STNA) #33 verified the sheets were soiled and the wall and overhead light had a substance scattered on the wall and light. Review of the policy titled, Quality of Life - Homelike EnvironmentBased on observations, medical record review, staff interviews, and policy review, the facility failed to ensure a safe, clean, and home-like environment. This affected two (#2 and #27) of 24 residents reviewed for environment. The facility census was 83.

Findings include:

1. Review of the medical record for Resident #2 revealed she was admitted to the facility on 04/13/18. Diagnoses included type two diabetes mellitus with other diabetic kidney complication, other sequelae of cerebral infarction, chronic kidney disease stage three, schizophrenia, morbid obesity due to excess calories, major depressive disorder, neuromuscular dysfunction of bladder, chronic obstructive pulmonary disease, cerebral ischemia, hyperlipidemia, and dysphagia following cerebral infarction.

Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/11/24, revealed this resident had severely impaired cognition. This resident was assessed to require moderate assistance with eating and oral hygiene, maximal assistance with bed mobility, and was dependent on staff for dressing, personal hygiene, transfer, toileting, and bathing.

Observation on 03/21/24 at 11:50 A.M., revealed there was a vertical gash with missing drywall and chipped paint in the wall near the baseboard behind the head of Resident #2's bed, which was visible when standing next to the bed.

Interview on 03/21/24 at 12:00 P.M., with Licensed Practical Nurse (LPN) #11 confirmed the gash in the wall in Resident #2's room.

2. Review of the medical record for Resident #27 revealed an admission date of 08/05/19. Diagnoses included progressive multifocal leukoencephalopathy (PML), parkinson's disease, major depressive disorder, bipolar disorder, anxiety disorder, and schizoaffective disorder.

Review of the Quarterly Minimum Data Set (MDS) assessment dated 02/09/24 revealed Resident #27 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. This resident was assessed to require supervision with toileting and transfers, and partial assistance with bathing and dressing.

Observations throughout the annual survey (03/18/24 - 03/21/24) revealed Resident #27's bed sheets had scattered brown substance at the head of the bed.

Observations throughout the annual survey (03/18/24 - 03/21/24) revealed Resident #27's wall behind her bed had scattered brownish-orange substance on the wall and the overhead light. The substance was scattered from the head of the bed to the foot of the bed.

Interview on 03/21/24 at 11:44 A.M., with State Tested Nurses Aide (STNA) #33 verified the sheets were soiled and the wall and overhead light had a substance scattered on the wall and light.

Review of the policy titled, Quality of Life - Homelike Environment

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

Based on record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, and staff interviews, 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 #13, #22, #72, and #80) out of four residents that were reviewed for medications administered by a contracted ancillary provider. This also affected 11 current residents (Residents #1, #3, #4, #8, #14, #37, #71, #75, #76, #87, and #90) and 16 discharged residents (Residents #100, #101, #102, #103, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, #114, and #115) that were identified by the facility as having received medication from the unlicensed source. The census was 90.

Findings include:

1. Review of the medical record for Resident #13 revealed he was admitted to the facility on 08/18/22. Diagnoses included chronic obstructive pulmonary disease, major depressive disorder, hyperlipidemia, obesity, and diabetes mellitus due to underlying condition with diabetic neuropathy.

Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/17/23, revealed Resident #13 had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require limited assistance for bed mobility, transfer, dressing, and toilet use as well as supervision for personal hygiene and eating.

Review of the plan of care revised on 08/17/23 revealed the resident was at nutritional risk related to diagnoses of diabetes mellitus, chronic obstructive pulmonary disease, hyperlipidemia, and depression. The resident was also at risk for dehydration related to diuretic use. Interventions included monitoring intakes, labs, weights and skin assessments, and observing signs/symptoms of dehydration.

Review of the physician orders dated 06/05/23, 07/18/23, 08/15/23, and 09/19/23 revealed orders for nutrition Agency #700 IV therapy infusion one time (500 milliliters (ml)) 0.9 % normal saline at 500 ml/hour (total additive volume 27.4 ml) with vitamin c 5 grams (gm), B complex, {Thi 200 milligrams (mg), Rib 4 mg, Nia 200 mg, Dex 4 mg, Pyr 4 mg, B5 250 mg, Methyl 2 mg, Magnesium Chloride 1000 mg, Calcium Chloride 200 mg, Zinc 10 mg, Glutamine 150 mg, Arg 500 mg, Orn 150 mg, Lys 250 mg, Cit 250 mg, and BCAA 2 ml}.

2. Review of the medical record for Resident #22 revealed she was admitted to the facility on 10/04/22. Diagnoses included renovascular hypertension, other cerebral infarction, psychotic disorder with delusions due to known physiological condition, major depressive disorder, vascular dementia unspecified severity with other behavioral disturbance, anorexia, generalized anxiety disorder, nutritional anemia, chronic kidney disease stage three, atherosclerosis of renal artery, mixed hyperlipidemia, renal osteodystrophy, and unspecified severe protein-calorie malnutrition.

Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/03/23, revealed Resident #22 had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 11. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, and toilet use, limited assistance for personal hygiene, and supervision for eating.

Review of the plan of care revised on 08/29/23 revealed the resident was at risk for decline in nutritional status due to diagnoses of protein-calorie malnutrition, chronic kidney disease stage three, hyperlipidemia, anemia, and metabolic encephalopathy. Interventions included house supplements, monitoring intakes, labs, weights and skin assessments, vitamins and minerals as ordered, and observe for signs/symptoms of dehydration.

Review of the physician orders dated 06/05/23, 07/18/23, 08/15/23, and 09/19/23 revealed orders for nutrition Agency #700 IV therapy infusion one time (500 milliliters (ml)) 0.9 % normal saline at 500 ml/hour (total additive volume 27.4 ml) with vitamin c 5 grams (gm), B complex, {Thi 200 milligrams (mg), Rib 4 mg, Nia 200 mg, Dex 4 mg, Pyr 4 mg, B5 250 mg, Methyl 2 mg, Magnesium Chloride 1000 mg, Calcium Chloride 200 mg, Zinc 10 mg, Glutamine 150 mg, Arg 500 mg, Orn 150 mg, Lys 250 mg, Cit 250 mg, and BCAA 2 ml}.

3. Review of the medical record for Resident #72 revealed he was admitted to the facility on 09/03/19. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, other sequelae of cerebral infarction, major depressive disorder, morbid (severe) obesity due to excess calories, cardiomyopathy, anemia, hyperlipidemia, vitamin d deficiency, and congestive heart failure.

Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/07/23, revealed Resident #72 had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 11. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, and toilet use as well as supervision for personal hygiene and eating.

Review of the plan of care revised on 10/17/23 revealed the resident was at risk for decline in nutritional status due to congestive heart failure, anemia, obesity, vitamin d deficiency, and prediabetes. The resident was also at risk for dehydration related to diuretic therapy. Interventions included house supplements, monitoring intakes, labs, weights and skin assessments, and observing for signs/symptoms of dehydration.

Review of the physician orders dated 06/05/23, 07/18/23, 08/15/23, and 09/19/23 revealed orders for Agency #700 IV therapy infusion one time 500 ml 0.9% normal saline at 500 ml/hour (total additive volume 30.4 ml) with vitamin c 5 gm, B complex, {{Thi 200 milligrams (mg), Rib 4 mg, Nia 200 mg, Dex 4 mg, Pyr 4 mg, B5 250 mg, Methyl 2 mg, Biotin 20 mg, Magnesium Chloride 1000 mg, Calcium Glutamine 200 mg, Zinc 10 mg, Glutamine 150 mg, Arg 500 mg, Orn 50 mg, Lys 250 mg, Cit 250 mg, Tau 100 mg, and Gly 100 mg}.

4. Review of the medical record for Resident #80 revealed she was admitted to the facility on 08/04/16. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder, unspecified convulsions, other specified anemias, mixed hyperlipidemia, and chronic obstructive pulmonary disease.

Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 05/25/23, revealed Resident #80 had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 04. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, and eating, and was totally dependent on staff for toilet use and personal hygiene.

Review of the plan of care revised on 09/19/23 revealed the resident was at nutritional/hydration risk due to diagnoses of hypertension, hyperlipidemia, cerebrovascular accident, and anemia. Interventions included monitoring intakes, labs, skin assessments and weights, and observing for signs/symptoms of dehydration.

Review of the physician order dated 06/05/23 revealed an order for Agency #700 IV therapy infusion one time 500 ml 0.9% normal saline at 500 ml/hour (total additive volume 30.4 ml) with vitamin c 5 gm, B complex, {{Thi 200 milligrams (mg), Rib 4 mg, Nia 200 mg, Dex 4 mg, Pyr 4 mg, B5 250 mg, Methyl 2 mg, Biotin 20 mg, Magnesium Chloride 1000 mg, Calcium Glutamine 200 mg, Zinc 10 mg, Glutamine 150 mg, Arg 500 mg, Orn 50 mg, Lys 250 mg, Cit 250 mg, Tau 100 mg, and Gly 100 mg}.

Interview with Representative #405 for the ancillary provider (Agency #700) 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 after 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 12/06/23 at 11:45 A.M. with the Administrator revealed the facility's corporate staff arranged the services with Agency #700. The Administrator stated he was unaware the provider lacked a TDDD license for the State of Ohio to provide medications.

Interview on 12/06/23 at 11:48 A.M. with the Director of Nursing (DON) revealed corporate notified the facility that services from Agency #700 would no longer be utilized but provided no further information. The DON stated she was unaware the provider lacked a TDDD license for the State of Ohio to supply medications. The DON verified the above listed residents received the medications and denied any residents experienced any adverse outcomes.

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 11/20/23 when the facility implemented the following corrective actions:

By 09/19/23, Agency #700 infusions were no longer being utilized.

By 11/20/23, all residents that received Agency #700's infusions were assessed with no negative outcomes noted.

By 11/20/23, education was provided to Corporate Staff, the Administrator, DON, and Medical Director related to utilizing providers with proper credentials.

By 11/20/23, all contracted suppliers were reviewed for appropriate credentials and will be reviewed annually moving forward.

Interview on 12/06/23 at 1:33 P.M. with the Administrator and DON confirmed education was received regarding TDDD licenses and only using providers with appropriate credentials.

This deficiency represents non-compliance investigated under Complaint Number OH00148171.

Based on record review, resident and staff interviews, and review of the facility policy, the facility failed to ensure resident medications were available for administration as ordered. This affected two (#25 and #40) of three residents reviewed for medication administration. The census was 85.

Findings include:

1. Review of the medical record for Resident #25 revealed an admission date of 02/12/20 with diagnoses including acute congestive heart failure (CHF), hypertension (HTN), intervertebral disc degeneration, diabetes mellitus (DM), ischemic cardiomyopathy, atherosclerotic heart disease, generalized anxiety disorder, and radiculopathy.

Review of the care plan for Resident #25 dated 04/14/20 revealed the resident had a diagnosis of anxiety disorder. Interventions included the following: administer medications as ordered, monitor/document for side effects and effectiveness, anticipate and meet the resident's needs, caregivers to provide opportunity for positive interaction, attention.

Review of the Minimum Data Set (MDS) assessment for Resident #25 dated 11/07/22 revealed resident was cognitively intact and was independent with activities of daily living (ADL's).

Further review of the December 2022 monthly physician orders for Resident #25 revealed an order dated 01/09/22 for the resident to receive Xanax routinely at bedtime once daily for treatment of generalized anxiety disorder.

Review of the progress note for Resident #25 dated 11/27/22 revealed the facility was pending a script for the resident's Xanax.

Review of the controlled substance sheets for Resident #25's Xanax revealed doses for 11/26/22 and 11/27/22 were not documented as administered.

Review of the emergency box records revealed a dose of Xanax was pulled on 11/26/22 for administration to Resident #25.

Interview on 12/09/22 at 9:28 A.M. with Resident #25 confirmed the facility did not renew the prescription for his routine Xanax in November of 2022 and on at least one or two nights he did not receive his routine dose of Xanax which caused him undue anxiety and nervousness.

Interview on 12/09/22 at 12:15 P.M. with Registered Nurse (RN) #130 confirmed routine doses of Xanax for Resident #25 were not documented as administered on 11/26/22 and 11/27/22. RN #130 further confirmed she would check the emergency box supply to determine if any doses were pulled from the emergency supply for Resident #25.

Interview on 12/09/22 at 3:00 P.M. with RN #130 confirmed the facility pulled a dose of Xanax from the emergency supply for Resident #25 on 11/26/22 but confirmed the facility had no documentation the resident received a dose of Xanax on 11/27/22.

2. Review of the medical record for Resident #40 revealed an admission date of 08/01/20 with a diagnosis of unspecified intracranial injury.

Review of the care plan for Resident #40 dated 10/20/22 revealed resident was at risk for developing complications secondary to being on pain medication therapy related to disease process. Interventions included the following: administer medications as ordered, ask physician to review medication if side effects persist, monitor respiratory rate, depth, and effort after administration of pain medications, monitor for altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritus, respiratory distress, sedation, urinary retention. observe for adverse reactions with every interaction with the resident, monitor for increased risk for falls.

Review of the MDS assessment for Resident #40 dated 11/16/22 revealed the resident was cognitively impaired and required extensive assistance of one staff with ADL's.

Further review of the December 2022 monthly physician orders for Resident #40 revealed an order dated 01/25/22 for the resident to receive Tramadol routinely twice daily for pain.

Review of the progress notes for Resident #40 dated 12/02/22 and 12/03/22 revealed the resident's Tramadol was not available for administration.

Review of the controlled substance sheets for Resident #40's Tramadol revealed doses for 12/02/22 at 9:00 A.M. and at 9:00 P.M., 12/03/22 at 9:00 A.M. and 9:00 P.M. and 12/04/22 at 9:00 A.M. were not documented as administered.

Review of the emergency box records revealed there were no doses of Tramadol pulled for Resident #40 from 12/02/22 to 12/04/22.

Interview on 12/09/22 at 12:15 P.M. with RN #130 confirmed routine doses of Tramadol for Resident #40 were not documented as administered on 12/02/22 at 9:00 A.M. and at 9:00 P.M., 12/03/22 at 9:00 A.M. and 9:00 P.M. and 12/04/22 at 9:00 A.M. RN #130 further confirmed she would check the emergency box supply to determine if any doses were pulled from the emergency supply for Resident #40.

Interview on 12/09/22 at 3:00 P.M. with RN #130 confirmed the facility had not pulled any doses of Tramadol from the emergency supply for Resident #40 on 12/02/22 through 12/04/22.

Review of the facility policy titled administering medications dated April 2019 revealed medications are administered in a safe and timely manner, and as prescribed.

This deficiency represents non-compliance investigated under Complaint Number OH00137890.

Based on record review, observation, staff interview, and review of the facility policy, the facility failed to ensure medications were prepared/stored in a safe manner and per professional standards of care. This affected two (#40 and #42) of seven residents reviewed for medications. The census was 85.

Findings include:

1. Review of the medical record for Resident #40 revealed an admission date of 08/01/20 with a diagnosis of unspecified intracranial injury.

Review of the Minimum Data Set (MDS) assessment for Resident #40 dated 11/16/22 revealed the resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADL's).

Review of the December 2022 monthly physician orders for Resident #40 revealed orders for Tramadol 50 milligram (mg) tablet per gastrostomy tube at 9:00 A.M. and Ativan one mg per g-tube at 9:00 A.M.

2. Review of the medical record for Resident #42 revealed and admission date of 01/28/15 with a diagnosis of multiple sclerosis (MS).

Review of the MDS assessment for Resident #42 dated 11/22/22 revealed the resident was cognitively impaired and was totally dependent on the assistance of one to two staff with ADL's.

Review of the December 2022 monthly physician orders for Resident #42 revealed orders for Tramadol 50 mg tablet per gastrostomy tube at 9:00 A.M.

Observation on 12/09/22 at 8:39 A.M. with Licensed Practical Nurse (LPN) #100 revealed there were approximately 25 plastic cups on top of the Third Floor Even medication cart. The cups had residents' first names written on them with marker. A cup with Resident #40's first name contained three pills, and a cup with Resident #42's first name contained one pill. LPN #110 was standing at the cart with the plastic cups when the surveyor approached nurse for an interview.

Interview on 12/09/22 at 8:39 A.M. with LPN #110 confirmed she had labeled plastic cups with the first names of all her assigned residents on the Third Floor Even cart. LPN #110 further confirmed she had pulled medications for Resident #40 which included: Tramadol 50 mg, Ativan one mg, and Claritin 10 mg. LPN #110 confirmed Resident #40 did not have an order for Claritin. LPN #110 confirmed she then pulled medication for Resident #42 which included Tramadol 50 mg. LPN #110 confirmed she had not signed out the controlled substance medications, Tramadol and Ativan, upon removing them from the compartment in the cart for medication storage.

Observation on 12/09/22 at 8:43 A.M. with LPN #110 revealed nurse took the empty plastic cups and the cups containing medications for Residents #40 and #42 and placed them in the top drawer of the cart. LPN #100 then left the floor. Further observation revealed LPN #110 administered medications to Residents #43 at 8:43 A.M., to Resident #45 at 8:48 A.M., to Resident #46 at 8:54 A.M., to Resident #50 at 9:05 A.M. for a total of 28 medication opportunities.

Interview on 12/09/22 at 9:10 A.M. with LPN #110 confirmed her usual practice in administering medications was to label cups with all the resident's names on them and then to pull all the controlled substances for administration for all the residents on the assignment first and then she would add in the other non-controlled substance medications as she went from room to room to administer medications.

Interview on 12/09/22 at 10:19 A.M. with LPN #100 confirmed LPN #110 had preset medications for Residents #40 and #42 and this included controlled substance medications. LPN #100 confirmed nurses should not preset medications to help prevent medication errors. LPN #100 confirmed medications should be given for one resident at a time before going on to the next resident. LPN #100 confirmed controlled substances needed to be signed out when removed from storage and should be administered as opposed to being repackaged and stored in top drawer of the cart.

Interview on 12/09/22 at 10:55 A.M. with Registered Nurse (RN) #130, the facility Assistant Director of Nursing (ADON) confirmed she had head about LPN #110 improperly handling (presetting) and improperly storing controlled substance medications. RN #130 confirmed the facility would provide corrective education for LPN #110 because she had violated the facility policies.

Review of the facility policy titled Administering Medications dated April 2019 revealed the individual administering the medication initials the resident's Medication Administration Record (MAR) on the appropriate line after giving each medication and before administering the next ones. Medications are administered in a safe and timely manner, and as prescribed.

Review of the facility policy titled Storage of Medications dated April 2019 revealed the facility stores all drugs and biological's in a safe, secure, and orderly manner. Drugs and biological's are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers.

Review of the facility policy titled Controlled Substances undated revealed controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents.

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

Based on medical record review, staff interview, and policy review, the facility failed to ensure resident medications were accurately documented when administered or refused. This affected one (#29) out of three residents reviewed for medication administration. The facility census was 87.

Findings include:

Review of the medical record for Resident #29 revealed he was admitted to the facility on 03/26/21 with diagnoses including but not limited to type two diabetes mellitus with proliferative diabetic retinopathy without macular edema, anemia, obstructive and reflux uropathy.

Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/13/22, revealed Resident #29 had intact cognition.

Review of Resident #29's Medication Administration Record (MAR) from 09/01/22 through 10/20/22 revealed medications were not signed off as administered or refused on 09/02/22, 09/04/22, 09/05/22, 09/07/22, 09/09/22, 09/10/22, 09/11/22, 09/13/22, 09/14/22, 09/17/22, 09/19/22, 09/20/22, 09/23/22, 09/24/22, 09/25/22, 09/26/22, 09/27/22, 09/28/22, 09/30/22, 10/01/22, 10/02/22, 10/04/22, 10/06/22, 10/07/22, 10/10/22, and 10/12/22.

Interview with Resident #29 on 10/24/22 between 8:25 A.M. and 8:45 A.M. revealed he received his medications as ordered.

Interview via phone on 10/24/22 at 8:59 A.M. with the Director of Nursing (DON) revealed there were issues with staff being able to document in the electronic health record following medication administration. The DON expressed residents would have reported if their medications had not been administered at all.

Review of the facility policy titled Administering Medications