Rocky River Gardens Rehab and Nursing Ctr

Based on interview and record review the facility failed to ensure resident funds were disbursed as required and in a timely manner after death. This affected one resident (Resident #120) of five residents reviewed for resident funds. The facility census was 110.

Findings include:

Review of Resident #120's medical record revealed an admission date of 11/21/23 and diagnoses including paranoid schizophrenia, unspecified psychosis, major depressive disorder, schizophrenia unspecified, unspecified severe protein-calorie malnutrition, psychotic disorder with hallucinations due to known physiological condition and history of COVID-19.

Review of a Minimum Data Set (MDS) 3.0 dated 02/22/24 revealed Resident #120 expired in the facility.

Review of a nurses' note dated 02/22/24 revealed Resident #120 expired in the facility.

Review of Resident #120's resident fund statement revealed as of 03/29/24, Resident #120 had an ending balance of $1069.28. There was no evidence of final disbursal for review.

Interview on 04/10/24 at 4:25 P.M. with Business Office Manager (BOM) #405 revealed she contacted Resident #120's guardian a week after she died regarding the funds and he had said he would contact the family. BOM #405 stated she never heard anything back after that. BOM #405 verified Resident #120's resident funds were not disbursed within 30 days as required after her death.

Based on record review and interview the facility failed to ensure a significant change Minimum Data Set (MDS) 3.0 assessment was completed for Resident #14. This affected one resident (#14) of 25 residents reviewed for MDS assessments. The facility census was 110.

Findings include:

Review of the medical record revealed Resident #14 was admitted to the facility on 11/25/19 with diagnoses including dementia with behavioral disturbance, diabetes, high blood pressure, anxiety, and depression.

Review of the physician orders for Resident #14 revealed the resident was admitted to hospice services on 02/20/24 for dementia with behavioral disturbance.

Review of the comprehensive annual MDS 3.0 assessment, dated 03/11/24 for Resident #14 under Section J, Health Conditions, revealed the resident was severely cognitively impaired and did not have a life expectancy of less than six months but was receiving hospice services.

Interview with MDS Registered Nurse (RN) #540 on 04/12/24 at 11:50 A.M. confirmed Resident #14 was receiving hospice services and Section J was coded incorrectly because a significant change assessment was not completed after the resident was admitted to hospice on 02/20/24. MDS RN #540 stated it was missed when she completed an MDS audit.

Based on observation, interview, and record review the facility failed to accurately complete Minium Data Set (MDS) assessments for Resident #5, #14 and #90. This affected three residents (Residents #5, #14, and #90) out of 25 residents reviewed for accurate Minium Data Set (MDS) assessments. The facility census was 110.

Findings Include:

1. A record review of Resident #5's medical record revealed Resident #5 was admitted to the facility on 01/06/24 with the diagnoses including high blood pressure, Chronic Obstructive Pulmonary Disease (COPD), history of falls with multiple fractures of the lumbar vertebrae, thoracic vertebrae, and skull. Resident #5 required assistance from staff, was cognitively intact and ambulated with a front wheeled walker and stand by assist of staff.

Review of Resident #5's signed physician orders for the month of April 2024 revealed orders including fall floor mat to right side of the bed dated 01/21/24, bed in the lowest position dated 01/21/24, and bed against the wall dated 01/21/24.

Review of Resident #5's assessments revealed admission fall risk assessment dated 01/06/24 Resident #5 was assessed as a high fall risk. Further fall risk assessments dated 01/10/24, 01/15/24, 01/16/24, 01/21/24, 04/07/24 continued to rate Resident #5 as a high fall risk.

Review of Resident #5's progress note dated 01/10/24 at 8:09 P.M. authored by LPN #409 revealed Resident #5 was observed laying in bed with a large hematoma located to the back of her head. There was a laceration observed in the center of the hematoma with moderate amount of bleeding observed. Resident #5 was sent to the hospital emergency room for evaluation and treatment.

Review of Resident #5's progress note dated 01/16/24 at 1:00 P.M. authored by LPN #442 revealed Resident #5 was observed face down on the floor of the bathroom. Resident #5 was attempting to use the bathroom independently. Resident #5 was observed with a laceration to the forehead and a skin tear located to the left hand. Resident #5 was sent to the hospital emergency room for evaluation and treatment.

Review of Resident #5's admission Minimum Data Set (MDS) 3.0 assessment dated 01/22/24 revealed Section J Health Conditions - J1800 Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS) was marked as No. Section J1900 Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS) B - Number of falls since Admission or Prior assessment - Injury was marked as No.

An observation on 04/11/24 at 9:51 A.M. revealed Resident #5 laying in a low bed against the wall with a blue fall mat located to the right side of the bed. Resident #5 was resting quietly watching television.

An interview on 04/11/24 at 12:15 P.M. with MDS Registered Nurse (RN) #540 confirmed Resident #5 had two falls on 01/06/24 and 01/10/24 with injury since admission to the facility on 01/06/24 and the admission MDS dated 01/22/24 was not completed accurately to reflect the two falls and the injury incurred.

2. A record review of Resident #5's medical record revealed Resident #5 was admitted to the facility on 01/06/24 with the diagnoses including high blood pressure, Chronic Obstructive Pulmonary Disease (COPD), history of falls with multiple fractures of the lumbar vertebrae, thoracic vertebrae, and skull. Resident #5 required assistance from staff, was cognitively intact and ambulated with a front wheeled walker and stand by assist of staff.

Review of Resident #5's admission assessment revealed there were no completed assessments for enabler or restraint used by Resident #5.

Review of Resident #5's admission Minimum Data Set (MDS) 3.0 assessment dated 01/22/24 revealed Section P - Restraints and Alarms P0100 Physical Restraints E. Trunk Restraints was marked as used less than daily.

An observation on 04/10/24 at 3:50 P.M. revealed Resident #5 was sitting independently on the edge of the bed eating a snack. There was a front wheeled walker located across the room from the bed. There was no wheelchair present in the room.

Interview on 04/11/24 at 10:00 A.M. with State Tested Nursing Assistant (STNA) #471 revealed Resident #5 ambulated with a front wheeled walker and stand by assist from staff. Resident #5 does not use a wheelchair or had any type of restraint or enabler for positioning in bed.

Interview on 04/11/24 at 12:15 P.M. with MDS RN #540 confirmed Resident #5 does not use a trunk restraint and the Admission MDS dated 01/22/24 was marked as a trunk restraint being used less than daily by Resident #5.

Based on record review, and interview the facility failed to ensure a skin assessment upon admission was timely obtained for the accurate initial assessment of skin impairment for Resident #11. This affected one resident (Resident #11) out of four residents reviewed for pressure ulcers. The facility census was 110.

Findings Include:

A record review for Resident #11 revealed Resident #11 was admitted to the facility on 02/01/24 with diagnoses including chronic kidney disease, heart failure, peripheral vascular disease (PVD), and Alzheimer's disease. Resident #11 had intact cognition and requires assistance from staff for personal hygiene cares, dressing, and transfers.

Review of Resident #11's baseline care plan dated 02/02/24 revealed interventions including use of pressure reducing mattress, pressure reducing cushion in wheelchair, encourage use of appropriate footwear while out of bed, and assess/monitor skin for impairments.

A review of Resident #11's admission assessment dated 02/02/24 revealed Resident #11 refused staff to perform a head-to-toe skin assessment to assess any skin impairments acquired prior to admission.

Review of Resident #11's progress notes dated 02/2/24 to 02/11/24 revealed no further documentation of attempts by staff to complete the admission head to toe skin assessment for Resident #11.

Review of Resident #11's weekly skin assessment dated 02/12/24 revealed abrasions located to bilateral lower legs. No further skin impairments were documented.

A review of Resident #11's shower/skin observation sheets dated 02/02/24 to 04/02/24 revealed no new skin areas were observed or noted by staff during Resident #11's showers and or bed baths.

An interview on 04/12/24 at 10:22 A.M. with facility wound nurse LPN #419 confirmed Resident #11 did not have an admission skin assessment completed by staff upon admission and there were no further attempts to complete a skin assessment due to Resident #11's initial refusal on admission to the facility. LPN #419 stated, The nurses should have attempted to complete the skin assessment within 8 hours of admission. If the resident refused, the nurse should have asked another nurse to attempt to complete the assessment.

Review of the facility's policy titled, Prevention of Pressure Ulcers/Injuries dated 07/01/17 revealed, Assess the resident on admission (within eight hours) for exiting pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any changes in condition.

2. Review of the medical record revealed Resident #109 was admitted to the facility on 10/31/23 with diagnoses including dementia with behavioral disturbance, prostate cancer, shared psychotic disorder, anxiety, and depression. Review of the physician orders for Resident #109 revealed an order for Zyprexa (an antipsychotic medication) 7.5 milligrams (mg) for mood at bedtime every day. Review of the pharmacist recommendations revealed on 12/21/23 the pharmacist requested an appropriate diagnosis for the use of the antipsychotic medication, Zyprexa, for Resident #109. The pharmacist provided appropriate diagnoses of Schizophrenia, Schizoaffective disorder, delusional disorder, mania, bipolar disorder, depression with psychotic features, refractory major depression, schizophreniform disorder, psychosis, atypical psychosis, or brief psychotic disorder, delirium with manic/psychotic symptoms. On 01/12/24 the psychiatric NP signed the pharmacist recommendation but did not provide an appropriate diagnosis for the use of Zyprexa for Resident #109. Interview with the Regional Director of Clinical Services on 04/11/24 at 1:30 P.M. confirmed the NP did not select an appropriate diagnosis provided by the pharmacist after signing the pharmacist's recommendation. Review of policy Medication Regimen Reviews2. Review of the medical record revealed Resident #109 was admitted to the facility on 10/31/23 with diagnoses including dementia with behavioral disturbance, prostate cancer, shared psychotic disorder, anxiety, and depression.

Review of the physician orders for Resident #109 revealed an order for Zyprexa (an antipsychotic medication) 7.5 milligrams (mg) for mood at bedtime every day.

Review of the pharmacist recommendations revealed on 12/21/23 the pharmacist requested an appropriate diagnosis for the use of the antipsychotic medication, Zyprexa, for Resident #109. The pharmacist provided appropriate diagnoses of Schizophrenia, Schizoaffective disorder, delusional disorder, mania, bipolar disorder, depression with psychotic features, refractory major depression, schizophreniform disorder, psychosis, atypical psychosis, or brief psychotic disorder, delirium with manic/psychotic symptoms.

On 01/12/24 the psychiatric NP signed the pharmacist recommendation but did not provide an appropriate diagnosis for the use of Zyprexa for Resident #109.

Interview with the Regional Director of Clinical Services on 04/11/24 at 1:30 P.M. confirmed the NP did not select an appropriate diagnosis provided by the pharmacist after signing the pharmacist's recommendation.

Review of policy Medication Regimen Reviews

Based on observation, interview, and record review the facility failed to assess and monitor the use of a necessary antipsychotic medication. This affected one resident (Resident #10) out of five residents reviewed for unnecessary medications. The facility census was 110.

Findings Include:

Observation on 04/10/24 at 10:15 A.M. revealed Resident #10 resting quietly in bed. Further observations on 04/11/24 at 2:25 P.M. and on 04/12/24 at 11:25 A.M. revealed Resident #10 resting quietly in bed with no behaviors observed.

A review of Resident #10's medical record revealed Resident #10 was admitted to the facility on 12/04/20 with the following diagnoses including Chronic Obstructive Pulmonary Disease (COPD), heart failure, high blood pressure, and Alzheimer's Disease. Resident #10 had impaired cognition and was dependent on staff for all personal hygiene cares, transfers and dressing.

Review of Resident #10's signed physician orders dated 04/01/24 revealed an order dated 12/25/23 for the use of antipsychotic medication Zyprexa 2.5 milligrams (MG) to be given daily for behaviors.

Review of Resident #10's Pharmacy Recommendations dated 09/10/23 revealed recommendation for the physician to address the diagnoses for the use of Zyprexa for behaviors. Response was marked as other - please see Doctor's Orders/Progress Notes.

Review of Resident #10's progress notes dated 09/10/24 to 10/01/24 revealed there was no documentation or entries to reflect the physician addressing or changing the diagnoses for the continued use of Zyprexa.

Review of Resident #10's behavioral documentation dated 02/01/24 to 04/11/24 revealed Resident #10 did not exhibit any behaviors which were documented by staff.

An interview on 04/12/24 at 12:01 P.M. with the Director of Nursing (DON) confirmed Resident #10's diagnosis for the use of Zyprexa was for behaviors, and Resident #10 was not exhibiting any behaviors in the last 90 days. The DON stated, The diagnosis of behaviors is not an appropriate diagnosis for the use of the antipsychotic medication Zyprexa. The resident has had no behaviors like she had on admission.

Review of the facility's policy titled, Medication regimen Reviews dated 04/01/07 revealed, The primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible.

Based on observation, interview, and record review the facility failed to maintain a medication administration error rate of less than 5%. The facility had 37 opportunities for medication error with two medication errors occurring resulting in a medication error rate of 5.41%. This affected one resident (Resident #46) out of four residents observed for medication administration. The facility census was 110.

Findings Include:

Medication administration observation on 04/11/24 at 7:25 A.M. revealed Licensed Practical Nurse (LPN) #476 preparing morning medication for Resident #46. LPN #476 placed the tablets into a medication pouch to be crushed and poured into a medication cup. LPN #476 took a soft gel capsule of Omega 3 Fish Oil and placed it in a separate pouch to crush and pour the liquid into the medication cup. The soft gel was crushed with a small amount of the liquid being poured into the medication cup. LPN #476 then took a soft gel capsule of B Vitamin Complex and placed it in a separate pouch to crush and pour the liquid into the medication cup. The soft gel was crushed with the liquid staying in the pouch. LPN #476 attempted to squeeze the liquid into the medication cup, this attempt was not successful, and the liquid medication remained in the pouch. LPN #476 mixed the crushed medications with applesauce and administered the medication to Resident #46.

Review of Resident #46's physician signed medication orders dated 04/01/24 revealed Resident #46 received the following medications during morning medication administration, Calcium Acetate 667 milligrams (mg), Abilify 20 mg, Aspirin 81 mg, Duloxetine 80 mg, Isosorbide Mononitrate 30 mg, Levetiracetam 250 mg, B-Complex Vitamin, Carvedilol 3.125 mg, Eliquis 5 mg, Omega 3 Fish Oil 1,000 mg, Ranolazine 1000 mg, and Topiramate 200 mg. Resident #46 required medications to be crushed for ease in swallowing.

Review of the manufacturing guidelines for Omega 3 Fish Oil revealed the soft gel capsules should not be crushed or split for the removal of the liquid may lead to incorrect dosage.

Review of the manufacturing guidelines for the B Vitamin Complex revealed the soft gel capsule form of the medication should not be pierced, split, or crushed due to the removal of the medication may lead to incorrect dosage.

Interview with LPN #476 confirmed the soft gel capsules of Omega 3 Fish Oil, and the B Vitamin Complex should not have been crushed, and a different form of the medication should have been used so that it could have been crushed and administered correctly.

Review of the facility's policy titled, Administering Medications revised in December 2012 revealed, Medications shall be administered in a safe and timely manner, and as prescribed.

Based observation, interview, and facility policy review the facility failed to keep medication in a secured environment, and failed to discard expired tuberculin solution. This had the potential to affect all 110 residents in the facility. The facility census was 110.

Findings Include:

1. Observation on 04/10/24 at 11:15 A.M. revealed the second-floor medication room door was ajar and not latched completely allowing the door to be pushed open without the use of the door handle. The door handle was part of a code locking system with the number 7 button stuck enabling the door to be unlocked.

Observation on 04/10/24 at 11:20 A.M. revealed the third-floor medication room door was closed but not locked. By turning the door handle it opened the door without having to enter the code to unlock the door.

Observation on 04/10/24 at 3:26 P.M. revealed State Tested Nursing Assistant (STNA) #418 opening the door of the third-floor medication room and entering without having a nurse as an escort into the medication room. STNA #418 then exited the medication with several boxes of gloves to be used in the resident's rooms.

Interview on 04/10/24 at 3:24 P.M. with Licensed Practical Nurse (LPN) #534 revealed the second-floor medication room door has not been able to be locked in several days due to the number 7 on the code box being stuck.

Interview on 04/10/24 at 3:30 P.M. with STNA #418 revealed the third-floor medication room was also where the resident supplies were stored, and the door had not been locked for several days. The STNAs could go into the medication room to get the supplies needed to take care of the residents.

Interview on 04/10/24 at 4:00 P.M. with the Director of Nursing (DON) confirmed the medication rooms on the second and third floors were unlocked, and the staff were able to enter and exit without using a code to unlock the doors.

Review of the facility policy titled, Storage of Medications dated 04/12 revealed, Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys.

2. Observation on 04/10/24 at 10:48 A.M. in the first floor medication refrigerator revealed two partially used vials of Apisol Tuberculin (TB) solution with out opened dates on either the vials or the manufacturer boxes.

Interview on 04/10/24 at 10:55 A.M. with Licensed Practical Nurse (LPN) #475 confirmed the two partially used TB solution vials without an opened date on the vials or the boxes. LPN #475 stated, Those vials and boxes should have an opened date on them.

Observation on 04/10/24 at 11:05 AM in the third floor medication room refrigerator revealed one partially used vial of Aplisol TB solution without an opened date on the vial or the manufacturer's box.

Interview on 04/10/24 at 11:10 A.M. with the Assistant Director of Nursing (ADON) confirmed the one partially used vial of Aplisol TB solution without an opened dated on the vial or the box. The ADON stated, The vials and the boxes should have an opened date and not be used passed 30 days from the opened date.

Review of the Aplisol TB solution manufacturer guidelines revealed, Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.

Based on observation, interview and policy review, the facility failed to ensure foods were labeled, dated and not retained when expired. This had the potential to affect 106 residents receiving food from the facility's kitchen as four residents (Residents #19, #41, #74 and #103) were ordered nothing-by-mouth (NPO). The facility census was 110. Findings include: Observation of the facility's nourishment refrigerators on 04/09/24 starting at 9:51 A.M. with Food Service Director (FSD) #440 revealed the following: In the first floor resident refrigerator, there were two expired yogurts dated 03/23/24, two expired yogurts dated 03/26/24 and a half-gallon of milk dated 04/04/24. In the second floor resident refrigerator, there was an unidentified pink substance on the inside base of the refrigerator and there was frozen popsicle material on the inside base of the freezer. In the third floor resident refrigerator, there were two containers labeled with Resident #85's room number on it but no date. Interviews with FSD #440 verified the above findings at the time of observation. FSD #440 indicated she or another dietary staff would check the refrigerators every Friday for expired food. FSD #440 stated housekeeping staff helped with this process but ultimately nursing staff were supposed to take expired food out of the refrigerators. FSD #440 stated these refrigerators were also cleaned weekly. FSD #440 confirmed there was no documentation regarding staff going through these refrigerators for expired food. Review of the facility policy, Food Brought by Family/VisitorsBased on observation, interview and policy review, the facility failed to ensure foods were labeled, dated and not retained when expired. This had the potential to affect 106 residents receiving food from the facility's kitchen as four residents (Residents #19, #41, #74 and #103) were ordered nothing-by-mouth (NPO). The facility census was 110.

Findings include:

Observation of the facility's nourishment refrigerators on 04/09/24 starting at 9:51 A.M. with Food Service Director (FSD) #440 revealed the following:

In the first floor resident refrigerator, there were two expired yogurts dated 03/23/24, two expired yogurts dated 03/26/24 and a half-gallon of milk dated 04/04/24.

In the second floor resident refrigerator, there was an unidentified pink substance on the inside base of the refrigerator and there was frozen popsicle material on the inside base of the freezer.

In the third floor resident refrigerator, there were two containers labeled with Resident #85's room number on it but no date.

Interviews with FSD #440 verified the above findings at the time of observation. FSD #440 indicated she or another dietary staff would check the refrigerators every Friday for expired food. FSD #440 stated housekeeping staff helped with this process but ultimately nursing staff were supposed to take expired food out of the refrigerators. FSD #440 stated these refrigerators were also cleaned weekly. FSD #440 confirmed there was no documentation regarding staff going through these refrigerators for expired food.

Review of the facility policy, Food Brought by Family/Visitors

Based on record review, interview, and review of policy and procedure, the facility failed to ensure accurate documentation of a resident's weight in the medical record. This affected one resident (#107) of three residents (#41, #114, and #107) reviewed for nutrition. The facility census was 110.

Findings include:

Review of the medical record for Resident #107 revealed an admission date of 08/23/23. Diagnoses included chronic kidney disease, diabetes mellitus with diabetic nephropathy, protein-calorie malnutrition, and dementia with behavioral disturbance.

Review of the quarterly minimum data set (MDS) assessment dated 03/01/24 revealed Resident #107 had impaired cognition, weighed 175 pounds (lbs.), had no significant weight changes, and did not receive a specialized diet.

Review of the weights and vitals summary for Resident #107 revealed:

08/23/23 174.4 lbs. on standup scale

10/01/23 172.3 lbs. on standup scale

12/15/23 176.2 lbs. while in wheelchair

01/17/24 175.2 lbs. on standup scale

02/08/24 174.7 lbs. while in wheelchair

03/07/24 173.6 lbs. on standup scale

03/09/24 173.6 lbs. while in wheelchair

03/22/24 175.0 lbs. using a mechanical lift scale

03/24/24 174.2 lbs. while in wheelchair

03/26/24 127.7 lbs. using Hoyer (mechanical lift scale)

04/05/24 126.4 lbs. while in wheelchair

Interview on 04/11/24 at 5:12 P.M. with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #436 revealed Resident #107 had always been thin and never a huge guy. LPN #436 stated the weight of 170 lbs. were most likely inaccurate and that the resident ate 50-100 % of his meals. DON stated Resident #107's son was a physician who visited often and had no concerns.

Interview on 04/12/24 at 11:11 A.M. with the DON and Registered Dietitian (RD) #541 stated Resident #107 had a large wheelchair that weighed 40.8 lbs. and that the documented weights dated 08/23/23 through 03/24/24 included the wheelchair weights. DON stated the resident was always weighed in his wheelchair and the documented methods of weighing Resident #107 standing or using the mechanical lift were also inaccurate. DON stated the resident did not require the use of the mechanical life. DON and RD #541 stated Resident #107 weight had been consistent with no significant weight changes and had not appeared with any significant weight changes. RD #541 stated the resident had a recent hospitalization and had some weight loss but had a gained. RD #541 stated Resident #107 was reweighed today at 131 lbs.

Reviewed policy Charting and Documentation revised July 2017 revealed documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, staff interview, and review of a company price quote document, the facility failed to maintain the parking lot in a safe manner. This had the potential to affect all 110 residents residing in the facility. The facility census was 110.

Findings include:

Observation of the front and back parking lots of the facility on 12/15/23 between approximately 8:30 A.M. and 9:30 A.M. revealed several potholes and significantly damaged pavement in both parking lots. Observation of the front side portion of the parking lot revealed an area measuring 27 feet and four (4) inches long by 13 feet and eight (8) inches wide near a storm drain that had multiple sunken areas with standing water and areas of cracked pavement. Additional observation of the front side parking lot revealed a pothole measuring approximately 26.5 inches long by 22.5 inches wide by approximately three (3) inches deep down to a pebble base, and an area of sunken and broken pavement measuring five (5) feet and 5 inches long by 34.5 inches wide. Observation of the back side parking lot revealed a pothole measuring approximately 3 feet and 5 inches long by 24 inches wide by 3 inches deep down to a pebble base, and a sunken area surrounding a storm drain with missing portions of pavement, and several areas of cracked and depressed pavement measuring approximately 13 feet and 8 inches by seven (7) feet wide.

Interview with Maintenance Director (MD) #900 on 12/15/23 at 8:45 A.M. verified the appearance of the front and back parking lots, and verified the area of damage noted in the parking lot observations. MD #900 further explained price quotes and work bids to repair the parking lots were obtained by the facility some time ago, and stated the company's corporate office had yet to approve the repairs.

Review of a company price quote document provided by a local asphalt company dated 03/16/22 revealed a comprehensive repair quote was provided to the facility for $56,800.00 to complete the repairs. There was no further follow-up to the parking lot repairs noted by the facility.

This deficiency represents non-compliance investigated under Complaint Number OH00148014.

Based on medical record review, staff interview, and review of policy, the facility failed to ensure a resident's advanced directives were accurately recorded throughout the medical record. This affected one (#35) of three residents reviewed for advance directives. The facility census was 103.

Findings include:

Record review for Resident #35 revealed an admission date of 06/17/22, with diagnoses including chronic obstructive pulmonary disease (COPD), and dementia, unspecified without behavioral disturbances.

Record review of the quarterly Minimum Data Set (MDS) assessment dated 03/06/23 revealed Resident #35 was severely cognitively impaired. Resident #35 required supervision of one-person physical assistants for bed mobility, transfers, ambulation, and toileting. The MDS included bathing itself did not occur. Resident #35 received hospice care.

Review of the care plan dated 11/03/22 revealed Resident #35 received hospice care need due to the diagnosis of end stage COPD. Interventions included to allow patient or surrogate to make advanced directive choices as needed. Hospice staff to visit and provide care, assistance, and/or evaluation in addition to facility staff.

Review of the physician orders revealed Resident #35 had an active physician order dated 07/27/22 for full code status. Additional orders included Resident #35 was admitted to Hospice services dated 01/16/23.

Review of Resident #35's hard medical record revealed under the section of Advanced Directives was a form with large written words Full Code.

Review of Resident #35's hard medical record revealed a form titled Hospice Comprehensive Assessment and Plan of Care dated 01/19/23 through 05/11/23 which was located in front of Resident #35's hard medical record. The first page of the Hospice Comprehensive Assessment and Plan of Care dated 01/19/23 had an Advanced Directives section which revealed Resident #35 had a directive for Do Not Resuscitate (DNR)-Arrest.

Interview on 06/06/23 at 9:50 A.M., with Registered Nurse (RN) #611 revealed she was Resident #35's charge nurse. RN #611 revealed Resident #35 had orders to be a full code and confirmed she would look at the physician orders and the Advanced Directives in Resident #35's hard medical record to determine the advanced directives if Resident #35 went into cardiac arrest. RN #611 reviewed the physician orders and the Advanced directives in Resident #35's medical record and hard medical record and revealed she would treat Resident #35 as a full code and perform cardiopulmonary resuscitation (CPR) if Resident #35 went into cardiac arrest.

Interview on record review on 06/06/23 at 10:04 A.M., with Director of Nursing (DON) confirmed Resident #35's physician orders dated 07/27/23 revealed his code status was a full code. The section under Advanced Directives in the hard medical record revealed Resident #35 was a full code. DON also confirmed Resident #35's hard medical record revealed the Hospice Comprehensive Assessments and Plan of Care located in front of the record, dated 01/19/23 through 05/11/23 revealed Resident #35 had a directive for Do Not Resuscitate (DNR)-Arrest. DON revealed Resident #35 was to have a DNR-Arrest code status and not a full code. DON confirmed Resident #35's physician orders and Advanced Directives in the hard medical record were not updated to reflect the accurate code status.

Record review of the policy titled, Advance Directives revised December 2016 revealed information about whether the resident has executed an advanced directive shall be displayed prominently in the medical record. Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if changes are extensive. The care plan team will be informed of such changes and or revocations so that appropriate changes can be made in the resident assessment and care plan.

Based on record reviews, resident interviews and staff interviews, the facility failed to ensure care plans reflected resident needs. This affected three (#57, #14, and #252) of 32 resident records reviewed. The facility census was 103.

Findings include:

1. Review of Resident #57 medical record revealed the resident was admitted to the facility on 01/10/23. Diagnoses included chronic obstructive pulmonary disease (COPD), protein calorie malnutrition (PCM), muscle weakness, gait abnormalities, lack of coordination, and need for assistance for personal care.

Review of Resident #57's physician orders revealed the resident was to have behaviors assessed every shift.

Review of Resident #57's quarterly Minimum Data Set (MDS) assessment, dated 04/01/23, revealed the resident had intact cognition.

Review of nurses notes for Resident #57 dated 05/18/23 at 9:27 P.M., revealed a temporary agreement was made with the Director of Nursing (DON) to move him to a first-floor room. This decision was made after the resident went to the store without having a leave of absence (LOA) order from a physician.

Review of Resident #57's care plans revealed no evidence of plans for elopement risk and behaviors.

2. Review of Resident #14's medical record revealed the resident was admitted to the facility on 07/01/19. Diagnoses included hemiplegia, hemiparesis, non-traumatic intracerebral hemorrhage affecting left dominant side, cerebral infarction, dysphagia following cerebral infarction, cognitive communication deficit, speech disturbance, major depressive disorder, chronic kidney disease (CKD), and gastrostomy.

Review of Resident #14's physician orders, dated 01/20/22, revealed to check the resident for placement of hearing aids every shift.

Review of Minimum Data Set (MDS) quarterly assessment dated 04/14/23 revealed Resident #14 has hearing aids for communication.

Review of Resident #14's care plan dated 04/18/23 revealed no evidence of a plan for care and placement of hearing aids for communication.

Interview with MDS Nurse #533 on 06/12/23 at 10:18 A.M., confirmed Resident #57 and Resident #14 did not have evidence of needed care plans.

Based on observation, staff interviews, record review, and review of policy, the facility failed to provide bathing/showers for two dependent residents. This affected two (#35 and #73) of three residents reviewed for bathing/showers. The facility census was 103.

Findings include:

1. Review of Resident #35's medical record revealed an admission date of 06/17/22. Diagnoses included chronic obstructive pulmonary disease (COPD), and dementia, unspecified without behavioral disturbances.

Review of the care plan dated 07/15/22 revealed Resident #35 had an activity of daily living self-care performance deficit related to dementia. Interventions included assistants needed of one staff member for bathing/showering. The care plan dated 11/03/22 revealed Resident #35 received hospice care need due to the diagnosis of end stage COPD. Interventions included Hospice staff to visit and provide care, assistance, and/or evaluation in addition to facility staff.

Review of the quarterly Minimum Data Set (MDS) assessment dated 03/06/23 revealed Resident #35 was severely cognitively impaired. Resident #35 required supervision of one-person physical assistants for bed mobility, transfers, ambulation, and toileting. The MDS included bathing itself did not occur. Resident #35 received hospice care.

Review of the physician order dated 01/16/23 revealed Resident #35 was admitted to Hospice with a diagnosis of lung cancer.

Review of the facility tasks sheets revealed Resident #35 received her showers/baths on Wednesdays and Saturdays, third shift, 11:00 P.M. to 7:00 A.M. The tasks revealed the last shower Resident #35 received was 05/25/23 at 12:16 A.M.

Review of the posted shower schedule located at the nurse's station revealed Resident #35 was to receive showers every Tuesday and Friday on day shift.

Observation on 06/05/23 at 9:00 A.M., revealed Resident #35 was ambulating in the hall. Resident #35's hair was very oily and unkept. Resident #35 revealed she did not know if she received baths or showers.

Interview on 06/05/23 at 9:04 A.M., with State Tested Nursing Assistant (STNA) #589 confirmed Resident #35's hair was oily and unkept.

Observation on 06/05/23 at 2:29 P.M., revealed Resident #35 was lying in bed. Resident #35's hair was very oily and unkept. Resident #35 requested no interview.

Interview on 06/06/23 at 3:04 P.M., with Unit Manager Licensed Practical Nurse (LPN) #574 revealed residents admitted to the facility will automatically go with the schedule located at the nurse's station. LPN #574 confirmed Resident #35 should have received her showers every Tuesday and Friday. LPN #574 revealed when showers were offered, a shower sheet for the resident would be completed by the STNA which included the shower was either completed or refused. LPN #574 revealed every resident should have a shower sheet completed for every scheduled shower day.

Interview on 06/06/23 at 3:14 P.M., with STNA #589 revealed she went by the shower schedule located at the nurse's station to determine if a resident was scheduled for a shower. If the shower or bath was given or offered, she would complete a shower sheet for that resident. STNA #589 revealed there were times there was not enough staff to complete showers and agency staff frequently did not complete their showers. STNA #589 revealed she tried but when she couldn't finish everything before the end of her shift, showers usually were the task not done.

Review of the shower sheets for Resident #35 revealed from 03/01/23 through 06/06/23, Resident #35 received a shower or bath on 03/04/23, 03/07/23, 03/31/23, 04/29/23, 05/16/23, 05/30/23, and 06/06/23. Resident #35 did not receive the remaining 23 scheduled baths/showers from 03/01/23 through 06/06/23.

Review on 06/07/23 at 3:30 P.M., of the facility tasks and shower sheets provided by the Director of Nursing (DON) revealed in the facility tasks, Resident #35 refused a shower on 03/19/23 and 03/26/23. DON confirmed the shower sheets provided for Resident #35 were all that were available and revealed there was no further documentation available to verify if Resident #35 received her baths/showers as scheduled by the facility. DON confirmed when a bath or shower was given to a resident, the confirmation would be placed on the shower sheet or in the facility tasks. DON confirmed there was no further documentation available to verify if Resident #35 received her baths/showers as scheduled by the facility. DON revealed if a resident was receiving hospice services, the facility staff were not expected to give showers.

Interview on 06/07/23 between 4:32 P.M. and 4:36 P.M., with STNA #570, #621, LPN #575 revealed there were times staff didn't have time to complete showers. If a resident received hospice services, the facility staff did not have to provide the resident's showers.

Interview on 06/13/23 at 3:00 P.M., with DON revealed there was no further documentation in Resident #35's medical record to verify when hospice services provided Resident #35 with a bath or shower.

Based on observations, medical record review, staff interviews, and policy review, the facility failed to timely assess newly identified skin areas and seek new treatment. This affected one (#80) of two residents reviewed for pressure ulcers. The facility identified four residents with pressure ulcers. The facility census was 103.

Findings include:

Review of the medical record for Resident #80 revealed an initial admission date of 05/10/22 and a recent readmission on 04/20/23. Diagnoses included but were not limited to unspecified hydro nephrosis, neuromuscular dysfunction of bladder, unspecified severe protein-calorie malnutrition, anoxic brain damage, dysphagia, need for assistance with personal care, and quadriplegia.

Review of 04/15/23 quarterly Minimum Data Set (MDS) assessment for Resident #80 revealed severe cognitive impairment. Resident #80 was noted to need extensive assist of one for bed mobility, locomotion on and off the unit, dressing, eating, toileting, and personal hygiene. Resident #80 was noted to be totally dependent upon staff for transfer. A stage IV pressure ulcer was noted to be present upon admission.

Review of Resident #80's care plan dated 06/01/23 revealed he had a pressure ulcer related to decreased mobility. Interventions included administering medications as ordered, administer treatments as ordered and monitor for effectiveness. Follow facility protocols for the prevention and treatment of skin breakdown. Monitor, document, and report as needed any changes in skin status, appearance, color, wound healing or signs and symptoms of infections, and wound size.

Review of the 05/03/23 Braden scale (tool for predicting pressure ulcer risk) revealed Resident #80 was at high risk for pressure ulcers.

Review of Resident #80's physician orders dated 03/20/23 revealed a treatment to the coccyx: cleanse with normal saline, pat dry, apply dermaseptin to peri-wound skin, calcium alginate to wound bed, ABD (wound dressing) to cover areas and tape to secure. Treatment to be completed every evening for wound care.

Review of Resident #80's physician orders dated 03/21/23 revealed a treatment to the right buttock: cleanse with normal saline, pat dry, apply dermaseptin to peri-wound skin, calcium alginate to wound bed, ABD pad to cover area and tape to secure. Treatment to be completed every evening for wound care.

Review of the 06/05/23 facility weekly skin assessment for Resident #80 revealed a stage four pressure wound on his coccyx with measures of 14 centimeters (cm) in length, 14 cm in width and 0.6 cm in depth and a stage three pressure wound on his right buttock which measured two and a half cm in length by 0.5 cm in width and 0.2 cm in depth.

Review of the June 2023 Treatment Administration Record for Resident #80 revealed no treatment for the new identified area of the right lower buttock that presented with red cluster area prior to the 06/08/23 observation during wound care.

Observation on 06/08/23 at 3:14 P.M., with Wound Care Nurse Licensed Practical Nurse (LPN) #563 and LPN #564 provide wound care to Resident #80's pressure wounds to the coccyx and right buttocks (located directly above the coccyx wound) revealed an additional wound was observed with no dressing by the surveyor to Resident #80's right hip area. The additional wound was open tissue, the wound bed was red, oval shaped, and the surrounding tissue was slightly reddened. After the wound care to the pressure wounds to the coccyx and right buttocks were completed, LPN #563 and #564 repositioned Resident #80 for comfort and confirmed the care for Resident #80's wounds were complete. Observation revealed no treatment was applied to the observed wound on Resident #80's right hip area that was visible during care. Surveyor interview and observation with Wound Care Nurse LPN #563 and #564 of the wounds to the right hip area confirmed this was a new wound and there were no treatment orders. Wound Care Nurse LPN #563 revealed she will report the new wound to hospice, and they will come out to assess, measure and provide a treatment order for the area. Wound Care Nurse LPN #563 confirmed that was hospices job.

Interview on 06/08/23 at 3:59 P.M. with Regional Nurse #617, Vice President of Clinical Services #620, and DON revealed the nurse finding the new wound on Resident #80 should have immediately assessed the wound at the time it was found and notified the physician for care and treatment. The nurse would then notify hospice services of the new wound and treatment provided.

Review of the 06/08/23 facility weekly skin assessment completed at 4:50 P.M. for Resident #80 revealed a new clustered red area on his right buttock which measured seven and a half cm in length by four cm in width.

Review of 06/08/23 physicians ordered timed at 5:15 P.M. for Resident #80 revealed a new treatment to right lower buttock to cleanse with normal saline, pat dry then apply barrier cream.

Review of the undated policy called; Wound and Skin Care revealed each resident will have a weekly skin assessment completed by a licensed nurse. Any alteration in skin integrity will be assessed, communicated to the physician, treatment order obtained, initiated and responsible party notified.

Based on record review, facility policy and procedure review and interview, the facility failed to provide Resident #30 adequate supervision and ensure proper footwear while ambulating to prevent a fall with injury. The facility also failed to complete a thorough fall investigation following the fall with injury.

Actual harm occurred on 02/23/23 when Resident #30, who was severely cognitively impaired, at risk for falls and required (staff) supervision with ambulation fell while ambulating independently and sustained a fractured right clavicle and right hip requiring surgical intervention. This affected one (#30) of three residents reviewed for falls. The facility census was 103.

Findings include:

Review of Resident #30's medical record revealed an admission date of 05/06/22 and re-admission 02/26/23, with diagnoses including asthma, dementia, and congenital kyphosis unspecified region.

Review of Resident #30's care plan dated 12/20/22 included Resident #30 had a self-care deficit related to dementia. Resident #30 would be clean, well groomed, and would have no decline from admission. Interventions included Resident #30 required supervision for ambulation and assistance of one staff member for grooming and hygiene. Further review revealed Resident #30 was at risk for falls. The goal developed was for Resident #30 to be free of falls (through review date). Interventions included to ensure Resident #30 was wearing appropriate footwear and to specify and describe correct client footwear, for example brown leather shoes, tartan bedroom slippers, black non-skid socks when ambulating.

Review of Resident #30's quarterly Minimum Data Set (MDS) 3.0 assessment dated 01/06/23 revealed Resident #30 had severe cognitive impairment. The assessment revealed Resident #30 required supervision of one staff member for bed mobility, transfers, toilet use and locomotion on the unit.

Review of Resident #30's progress note, dated 02/23/23 at 3:37 P.M., documented the nurse heard a loud noise, a State Tested Nursing Assistant (STNA) yelled for help and Resident #30 was found on the floor in the doorway to her room. Resident #30 was bleeding from her head, 911 was called, pressure was applied to head wound. Vital signs were taken. Resident #30 stated she lost her balance and tripped over her shoe. Resident #30 complained of pain to her right leg, right shoulder, pelvis, and head. Resident #30 had a laceration to the right eyebrow and a hematoma to the right side of her forehead. Resident #30 was transported to the local hospital Emergency Department. The Director of Nursing (DON), the Nurse Practitioner, and Resident #30's guardian were notified.

Review of Resident #30's progress notes dated 02/24/23 at 9:31 A.M., revealed Resident #30 was admitted to the hospital with a fractured right clavicle and had surgery, open reduction, and internal fixation right hip.

Interview on 06/08/23 at 8:46 A.M., with Regional Nurse #617 revealed she read the investigation report of Resident #30's fall. The investigation report revealed the nurse heard a loud noise, the STNA called for help, Resident #30 was on floor and said she tripped over her shoe. Two nurses and an aide assisted Resident #30. Resident #30 was bleeding, pressure applied to her head wound, 911 was called, vital signs were stable and blood pressure was 166/97. Resident #30 was confused with impaired memory. The Nurse Practitioner, Director of Nursing (DON) and responsible party were notified. A head-to-toe assessment was completed and Resident #30 was unable to state if she had pain in the past five days.

Interview on 06/08/23 at 8:46 A.M., with Assistant Director of Nursing/Licensed Practical Nurse (ADON/LPN) #529 revealed she watched the camera footage of Resident #30's fall. ADON/LPN #529 stated Resident #30's shoes were not all the way on her feet, and she was walking on the back of the shoes and tripped. ADON/LPN #529 stated she believed Resident #30 was high functioning for activities of daily living (ADL)'s and was able to put her own shoes on. ADON/LPN #529 stated Resident #30 was walking out of her room and tripped. ADON/LPN #529 indicated Resident #30 took naps throughout the day. ADON/LPN #529 stated the aide was charting three doors down from Resident #30 when she fell.

Interview on 06/08/23 at 10:08 A.M., with State Tested Nursing Assistant (STNA) #597 revealed he knew Resident #30 well and took care of her most days when he worked. STNA #597 stated he was not working on the nursing unit Resident #30 resided on the day she fell. STNA #597 stated before her fall Resident #30 needed assistance getting dressed, putting her pants and undergarments on. STNA #597 stated he had to put Resident #30's shoes on, and she could not do it herself.

Interview on 06/08/23 at 11:19 A.M., with Regional Nurse #617 revealed she read the witness statements from Licensed Practical Nurse (LPN) #565 and STNA #625 and the notes confirmed the progress note documentation. Regional Nurse #617 confirmed the investigation notes did not reveal the events leading up to the fall or if staff assisted Resident #30 with her shoes (prior to the incident/fall). Regional Nurse #617 confirmed the investigation did not state if Resident #30 was trying to use the bathroom, if she was alone or with other residents, or which shoes were on her feet.

Interview on 06/08/23 at 11:29 A.M., with LPN #565 revealed on 02/23/23 she was sitting at the nurse's station and saw Resident #30 walking back to her room. LPN #565 stated she heard a loud bang, ran to Resident #30 to assist her, and stayed with Resident #30 because she thought she fractured her hip by the way it looked. LPN #565 stated the DON was notified of Resident #30's fall. LPN #565 indicated Resident #30 tripped over her shoe when she was turning to enter her room. LPN #565 stated she could not remember if it was the right or left shoe, but stated one of her shoes was off and laying in the doorway. LPN #565 stated Resident #30 could walk independently, and she could not remember if Resident #30's shoes had shoelaces. LPN #565 indicated the fall occurred between lunch and dinner, and Resident #30 told her she was going to use the bathroom. LPN #565 stated the aide who assisted Resident #30 after the fall no longer worked at the facility.

Interview on 06/08/23 at 11:44 A.M., with ADON/LPN #529 revealed she only looked at the camera footage at the point of Resident #30's fall and could not tell if Resident #30 was walking in or out of her room. ADON/LPN #529 stated she just wanted to make sure no one pushed Resident #30 or if there was any obstruction in her path. ADON/LPN #529 did not know if Resident #30 was lying down before the fall, did not know what Resident #30 was doing before the fall, and if staff assisted her with her shoes or Resident #30 had tried to put her shoes on herself.

Interview on 06/08/23 at 12:52 P.M., with Regional Nurse #617 revealed no staff were interviewed to determine who (if anyone) put Resident #30's shoes on and helped her dress that day. Regional Nurse #617 indicated the investigation did not reveal if staff were interviewed about Resident #30 ambulating by herself.

Review of the policy titled Assessing Falls and Their Causes revised October 2010 included the purpose of the procedure was to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. After an observed or probable fall, the staff would clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred. Within 24 hours of the fall the nursing staff would begin to try to identify possible or likely causes of the incident. Staff would evaluate chains of events or circumstances preceding a recent fall including what the resident was doing, whether the resident was among other persons or alone and whether the resident was trying to get to the toilet.

2. Review of the medical record for Resident #3 revealed an admission date of 09/13/22. Diagnoses included congestive heart failure, type II diabetes, unspecified severe protein-calorie, hemiplegia, and hemiparesis following cerebral infarction affecting left non-dominant side, atrial fibrillation, adult failure to thrive, mental disorder not otherwise specified, major depressive disorder, and generalized anxiety disorder. The resident was admitted to hospice on 11/25/22.

Review of physician's order dated 09/13/22 revealed weekly weights times four weeks and then monthly. There were no current physician orders for weekly weights.

Review of Resident #3's weights revealed 111.8 pounds (#s) on 04/07/23 and 89.6 #s on 05/05/23 which indicated a 22.2 # weight loss over a 30-day interval. Resident #3 refused to be weighed for June 2023.

Review of the nutrition notes dated 04/20/23 and 05/19/23 assessed the resident and implement nutritional interventions, including recommendations for medication changes, increasing supplements and protein intakes and weekly weights for four weeks for weight monitoring.

Review of the May and June 2023, Medication Administration Record and Treatment Administration Record for Resident #3 did not reveal weekly weight monitoring was being completed.

Review of the May 2023 State Tested Nurse Assistant (STNA) task assignment for monthly weight monitoring for Resident #3 revealed no weights were recorded.

Interview on 06/13/23 at 2:20 P.M., with the Director of Nursing (DON) confirmed weekly weights were not ordered or completed for Resident #3 following the nutrition progress note recommendations on 05/19/23.

Review of the policy titled Weight Assessment and Intervention updated 01/10/23 included the multidisciplinary team would strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Monthly weights would be completed by the tenth of each month and weekly weights would be completed on a designated day each week at the facilities discretion. Weights will be recorded in the electronic medical record. Any weight change of five percent or more since the last weight assessment would be retaken the next day for confirmation. If the weight was verified, nursing would immediately notify the dietician in writing, Verbal notification must be confirmed in writing. Significant weight changes are identified as five percent weight loss in one month, seven and a half percent in three months and ten percent loss in six months.

Based on record review, staff interview, and policy review, the facility failed to ensure a licensed pharmacist completed monthly medication review (MMR). This affected two (#14 and #69) of the five residents reviewed for unnecessary medications. The facility census was 103.

Findings include:

1. Review of Resident #14's medical record revealed an admission date of 07/01/19, with diagnoses including: hemiplegia, hemiparesis, non-traumatic intracerebral hemorrhage affecting left dominant side, cerebral infarction, dysphagia following cerebral infarction, cognitive communication deficit, speech disturbance, major depressive disorder, and chronic kidney disease.

Review of Residents #14's medical record from June 2022 through May 2023 revealed no evidence of monthly pharmacy reviews being completed.

2. Review for Resident #69's medical record revealed an admission date of 03/31/20, with diagnoses including: paraplegia, muscle weakness, major depressive disorder, and generalized anxiety.

Review of Residents #69's medical record from April 2023 through May 2023 revealed no evidence of monthly pharmacy reviews being completed.

Interview on 06/13/23 at 10:00 A.M., with the Director of Nursing (DON) revealed the MMR's were not completed for Residents #14 and #69.

Review of the policy titled Medication Regimen Review Policy

4. Review of medical record for Resident #3 revealed an admission date of 09/13/22, with diagnoses including mental disorder not otherwise specified, major depressive disorder, and generalized anxiety disorder.

Review of the quarterly MDS assessment dated 03/08/23 revealed Resident #3 was severely cognitively impaired.

Review of Resident #3's care plan dated 11/17/22 revealed Resident #3 had impaired cognitive function/dementia or impaired thought process related to impaired decision making. Interventions included reviewing medications and record possible causes of cognitive deficit, new medications or dosage increases, anticholinergics, opioids, benzodiazepines, drug interaction, errors or adverse drug reaction, drug toxicity.

Review of the facility Consultant Pharmacist Recommendation to Physician form for Resident #3 dated 03/25/23 revealed the resident (#3) had been taking hydroxyzine 50 mg at bedtime (HS) since 11/08/22 without a gradual dose reduction (GDR). Could we attempt a dose reduction at this time to verify this resident is on the lowest possible dose? If not, please indicate response below. Review of the GDR revealed the form had no response documented from the physician.

Record review of the Medication Administration Record (MAR) for March 2023 to June 2023 revealed Resident #3 had no reduction of hydroxyzine during that time frame.

Interview on 06/13/23 at 2:20 P.M., with the Director of Nursing (DON) confirmed the Consultant Pharmacist Recommendation for Resident #3 was not initiated or completed. Resident #3 did not receive the recommended dose reduction of hydroxyzine.

Based on record review, hospice staff interviews and staff interview, the facility failed to coordinate care with hospice services in providing care for residents. This affected two (#35 and #80) of three residents reviewed who received hospice services. The facility census was 103.

Findings include:

1.Record review for Resident #35 revealed an admission date of 06/17/22. Diagnosis included chronic obstructive pulmonary disease (COPD), and dementia, unspecified without behavioral disturbances.

Record review of the quarterly Minimum Data Set (MDS) dated 03/06/23 revealed Resident #35 was severely cognitively impaired. Resident #35 received hospice care.

Record review of the care plan dated 07/15/22 revealed Resident #35 had an activity of daily living self care performance deficit related to dementia. Interventions included assistants needed of one staff member for bathing/showering. The care plan dated 11/03/22 revealed Resident #35 received hospice care need due to the diagnosis of end stage COPD. Interventions included Hospice staff to visit and provide care, assistance, and/or evaluation in addition to facility staff.

Record review of the physician order dated 01/16/23 revealed Resident #35 was admitted to Hospice (#625) with a diagnosis of lung cancer.

Record review of the posted shower schedule located at the nurses station revealed Resident #35 was to receive showers every tuesday and friday on day shift.

Observation on 06/05/23 at 9:00 A.M. revealed Resident #35 was ambulating in the hall. Resident #35's hair was very oily and unkept. Resident #35 revealed she did not know if she received baths or showers.

Observation on 06/05/23 at 9:04 a.m. with State Tested Nursing Assistant (STNA) #589 confirmed Resident #35 's hair was oily and unkept.

Record review of the shower sheets for Resident #35 revealed from 03/01/23 through 06/06/23 showers/baths were not consistently completed as scheduled.

Interview on 06/07/23 at 3:30 P.M. with DON revealed if a resident was receiving hospice services, the facility staff were not expected to give showers.

Interview on 06/07/23 between 4:32 P.M. and 4:36 P.M. with STNA #570, #621, LPN #575 revealed if a resident received hospice services, the facility staff did not have to provide the residents showers.

Record review of the hospice Certification and Plan of Care dated 05/11/23 located in the front of Resident #35's chart revealed no documentation of when scheduled shower/bathing days occurred.

Interview on 06/13/23 at 3:00 P.M. with DON revealed there was no documentation in Resident #35's medical record to verify when hospice services provided Resident #35 with a bath or shower. DON confirmed the facility did not meet with hospice as a team when residents were admitted to hospice to collaborate care for residents.

Phone interview on 06/13/23 at 4:20 P.M. with Hospice Nurse RN #623 from Hospice Service #625 for Resident #35 revealed the hospice staff provided supplemental care for Resident #35, the facility staff was to continue to provide routine care including showers. Hospice Nurse RN #623 revealed she did not sit with facility staff to coordinate care, she placed the care plan in the residents chart for the facility staff to review. Hospice Nurse RN #623 revealed she was not aware when Resident #35 received showers provided by the facility but when the hospice staff provided bathing, that was to be considered extra bathing.

2. Record review for Resident #80 revealed and admission date of 05/10/22. Diagnosis included anoxic brain damage, cognitive communication deficit, need for assistants with personal care, and hemiplegia and hemiparesis.

Record review of the quarterly Minimum Data Set dated 04/02/23 revealed Resident #80 was severely cognitively impaired. Resident #80 was at risk for pressure ulcers and had two stage four pressure ulcers.

Record review of the care plan for Resident #80 dated 06/01/23 revealed Resident #80 had a pressure ulcer or potential for a pressure ulcer developing related to decreased mobility. Interventions included to administer treatment as ordered.

Record review of the physician order dated 06/07/23 revealed an order for Resident #80 Admitted to Hospice 06/01/23 with diagnosis of anoxic brain damage.

Observation on 06/08/23 at 3:14 P.M. with Wound Care Nurse Licensed Practical Nurse (LPN) #563 and LPN #564 provide wound care to Resident #80's pressure wounds to the coccyx and right buttocks (located directly above the coccyx wound) revealed an additional wound was observed with no dressing by the surveyor to Resident #80's right hip area. The additional wound was open tissue, the wound bed was red, oval shaped, and the surrounding tissue was slightly reddened. After the wound care to the pressure wounds to the coccyx and right buttocks were completed, LPN #563 and #564 repositioned Resident #80 for comfort and confirmed the care for Resident #80's wounds were complete. Observation revealed no treatment was applied to the observed wound on Resident #80's right hip area that was visible during care. Surveyor interview and observation with Wound Care Nurse LPN #563 and #564 of the wound to the right hip area confirmed this was a new wound and there were no treatment orders. Wound Care Nurse LPN #563 revealed she will report the new wound to hospice, and they will come out to assess, measure and provide a treatment order for the area. Wound Care Nurse LPN #563 confirmed that was hospices job.

Interview on 06/08/23 at 3:59 P.M. with Regional Nurse #617, Vice President of Clinical Services #620, and DON revealed the nurse finding the new wound on Resident #80 should have immediately assessed the wound at the time it was found and notified the physician for care and treatment. The nurse would then notify hospice services of the new wound and treatment provided.

Interview on 06/13/23 at 3:00 P.M. with DON confirmed the facility did not meet with hospice as a team when residents were admitted to hospice to collaborate care for residents.

Phone interview on 06/13/23 at 4:40 P.M. with Hospice RN #624 from Hospice Service #626 for Resident #80 revealed hospice staff take over the residents care plan and would collaborated with the staff on the unit at the time of the visit. The nurses were expected to notify hospice first with any change in condition including finding a new wound. Hospice RN #624 revealed the nurse at the facility would not notify the physician first because the physician would not know the hospice formulary including for wound care. The nurse would be expected to just put a dressing over the wound until the hospice nurse could come and assess the wound and determine the treatment. Hospice RN #624 verified she was unsure how long it may take for a hospice nurse to arrive to assess the resident but that was how it should be done.

Based on observation, staff interview, record review, and review of policy, the facility failed to maintain infection control practiced during a wound dressing change. This affected one (#80) of two residents observed during wound dressing changes. The facility census was 103.

Findings include:

Record review for Resident #80 revealed and admission date of 05/10/22, with diagnoses including anoxic brain damage, cognitive communication deficit, need for assistants with personal care, and hemiplegia and hemiparesis.

Review of the quarterly Minimum Data Set dated 04/02/23 revealed Resident #80 was severely cognitively impaired. Resident #80 was at risk for pressure ulcers and had two stage four pressure ulcers.

Review of the care plan for Resident #80 dated 06/01/23 revealed Resident #80 had a pressure ulcer or potential for a pressure ulcer developing related to decreased mobility. Interventions included to administer treatment as ordered.

Record review of the physician order dated 06/07/23 revealed an order for Resident #80 admitted to Hospice 06/01/23 with diagnosis of anoxic brain damage.

Review of the physician orders for June 2023 for Resident #80 revealed the treatment to the coccyx included cleans with normal saline pat dry, apply dermaseptine to peri wound skin, calcium alginate to wound bed, abdominal pad to cover areas and tape to secure. The treatment to the right buttocks included cleans with normal saline pat dry, apply dermaseptine to peri wound skin, calcium alginate to wound bed, abdominal pad to cover areas.

Observation on 06/08/23 at 3:14 P.M., with Wound Care Nurse Licensed Practical Nurse (LPN) #563 and LPN #564 provide wound care to Resident #80's pressure wounds to the coccyx and right buttocks (located directly above the coccyx wound) revealed the old dressing (covering both wounds) dated 06/08/23 was saturated with yellow/brown drainage on the outside of the dressing and there was a large amount of thick, mucousy yellow/brown drainage covering the inside of the dressing. Wound Care Nurse LPN #563 verified the dressing removed was saturated. Wound Care Nurse LPN #563 removed the old dressings covering both wounds, cleansed both wounds, applied the new dressings completing the dressing changes. Observation revealed during the dressing changes, Wound Care Nurse LPN #563 did not remove her gloves and/or wash her hands after removing the soiled dressings and before applying the clean dressings.

Interview on 06/08/23 at 3:41 P.M., with LPN #564 confirmed Wound Care Nurse LPN #563 did not change her gloves or wash her hands during the dressing change with Resident #80.

Interview on 06/08/23 at 3:41 P.M. with Wound Care Nurse LPN #563 confirmed she did not wash her hands or change her gloves after removing the soiled dressing on Resident #80's wounds to the coccyx and right buttocks and before applying the clean dressings during the dressing change.

Review of the policy titled, Wound Care dated October 2010, revealed the purpose of the procedure is to provide guidelines for the care of wounds to promote healing. The steps in the procedure included to put on exam glove. Loosen tape and remove dressing. Pull glove over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly. Put on gloves.

Based on record review, interview, and facility policy review the facility failed to administer rapid-acting insulin in a timely manner. This affected two Residents (#5 and #6) of 15 residents who required insulin daily. The facility census was 104.

Findings include:

1. Review of the medical record for Resident #5 revealed an admission date of 09/11/21. Diagnoses included type two diabetes mellitus and need for assistance with personal care.

Review of the quarterly Minimum Data Set (MDS) assessment dated 03/31/23 revealed the resident had intact cognition.

Review of physician order for Resident #5 revealed an order for 18 units of Humalog solution (paid acting insulin) (dated 08/04/23) subcutaneously before meals for glucose control. The time of administration ordered by the physician was 6:30 A.M.

Review of breakfast service revealed Resident #5 was not expected to receive breakfast until 8:20 A.M.

Review of the medication administration records (MAR) for April 2023 revealed Resident #5 received18 units of Humalog insulin at 6:13 A.M. on 04/07/23, 5:50 A.M. on 04/08/23, 5:49 A.M. on 04/11/23, and 5:45 A.M. on 04/14/23.

2. Review of the medical record for Resident #6 revealed an admission date of 03/03/23. Diagnoses included type two diabetes mellitus with hypo/hyperglycemia.

Review of the quarterly MDS assessment dated 03/08/23 revealed Resident #6 had intact cognition.

Review of physician order for Resident #6 revealed an order for Humalog solution (dated 03/14/23) subcutaneously before meals (sliding scale) for glucose control. The time of administration ordered by the physician was 6:30 A.M.

Review of the MAR for April 2023 revealed Resident #6 received eight units of Humalog at 6:19 A.M. on 04/01/23, six units at 6:36 A.M. on 04/03/23, two units at 6:00 A.M. on 04/07/23, and eight units at 6:22 A.M. on 04/14/23.

Review of breakfast service revealed Resident #6 was not expected to receive breakfast unit 7:50 A.M.

Interviews on 04/14 23 from 8:08 A.M. to 8:43 A.M., Licensed Practical Nurse (LPN) #204, Registered Nurse (RN) #205, LPN #206 and LPN #207 stated rapid-acting insulin should be administered 10 to 15 minutes before meals.

Interviews on 04/14/23 from 10:57 A.M. to 11:03 A.M., Residents #5 and #6 stated they had no adverse effects from receiving insulin hours before a meal; however, both residents stated that staff had administered insulin a couple hours before breakfast was served.

Interview on 04/14/23 at 10:40 A.M., LPN #208 verified the administration times for Residents #5 and #6, and stated the insulin should be given right before meals to prevent low blood sugars.

Interview on 04/14/23 at 11:15 A.M., the Regional Director of Clinical Services (RDCS) #210, Assistant Director of Nursing (ADON) #211 and Administrator were informed of the concern related to the time of the insulin administration. RDCS # 210 stated rapid-acting insulins like Humalog should be administered 15-20 minutes before meals are consumed.

Review of the facility policy titled Insulin Administration

Based on observation, interview, record review, and facility policy review the facility failed to ensure medications were stored at the appropriate temperatures in the third-floor medication room. This affected two residents (#52 and #71) that had current medications stored in the medication refrigerator. This had the potential to affect an additional 31 residents (#1, #2, #5, #7, #8, #10, #12, #13, #16, #17, #19, #20, #24, #25, #26, #27, #31, #36, #37, #48, #49, #55, #57, #58, #61, #67, #68, #69, #72, #84 and #91) currently residing on the third floor of the facility. The facility census was 97.

Findings include:

1. Review of the medical record for the Resident #52 revealed an admission date of 02/24/22. Diagnoses included metabolic encephalopathy, diabetes mellitus, candida stomatitis, and heart failure.

Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated 01/04/23 revealed Resident #52 had moderately impaired cognition. The resident required extensive assistance of one staff for activities of daily living except eating which the resident required supervision.

Review of the physician's orders for January 2023 revealed Resident #52 was ordered Novolin N (Insulin NPH) 10 unit subcutaneously one time a day.

2. Review of the medical record for the Resident #71 revealed an admission date of 08/23/19 and a readmission date of 07/18/22. Diagnoses included chronic obstructive pulmonary disease, diabetes mellitus, dysphagia, and seizures.

Review of the quarterly MDS 3.0 assessment dated 12/31/22 revealed the resident had severely impaired cognition. Resident #71 required extensive assistance of two staff for activities of daily living except eating which the resident required extensive assistance of one staff.

Review of the physician's orders for January 2023 revealed Resident #71 was ordered Novolog (Insulin) inject subcutaneously per sliding scale.

Observation on 01/30/23 at 8:47 A.M. revealed the third-floor medication storage room was secure. In the medication refrigerator revealed the refrigerator was opened and had a temperature of 52 degrees Fahrenheit (F). This was verified by Licensed Practical Nurse (LPN) #109 at 8:33 A.M.

Inventory on 01/30/22 at 2:06 P.M. of third floor medication refrigeration revealed that there were four Novolin pens for Resident #52 and eight pens of Novolog for Resident #71. This was verified by LPN #109.

Interview on 01/30/22 at 2:06 P.M. with Director of Nursing (DON) revealed Novolin N and Novolog should be stored between two and eight degrees Celsius (35.6 degrees F to 46.4 degrees F) according to the pharmacist.

Review of the manufacturer's instructions for Novolin N and Novolog revealed the insulins should be stored between two and eight degrees Celsius (35.6 degrees F to 46.4 degrees F).

Review of the medication refrigerator log for the third floor revealed that the last temperature of 40 degrees F was taken on 01/28/23.

Review of the facility's policy dated April 2007 titled, Storage of Medications revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner.

This deficiency represents noncompliance investigated under Complaint Number OH00136761.

Based on observation, interview, record review, and facility policy review the facility failed to ensure physician ordered medications were available for administration. This affected one (Resident #1) of three residents reviewed for accurate medical records. The facility census was 95.

Findings include:

Review of the medical record revealed Resident #1 was admitted to the facility on 06/06/22 with diagnoses including human immunodeficiency disease (HIV), end stage renal disease, and depression. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated 06/18/22 revealed Resident #1 was cognitively impaired and was independent for activities of daily living.

Review of Resident #1's physicians orders for August 2022 revealed the resident was prescribed Ritonavir 100 milligrams (mg) once a day (antiviral to treat HIV).

Interview with Resident #1 on 08/28/22 at 1:45 P.M. revealed he had not received his Ritonavir 100 mg since last Tuesday (08/23/22).

Review of the medication administration record (MAR) revealed Resident #1 did not receive the physician ordered Ritonavir from 08/24/22 through 08/27/22. The MAR had an entry on 08/24/22 stating Resident #1 was out of the facility. Entries in the MAR stated see nurses notes on 8/25/22 and 08/27/22. On 08/28/22, the Ritonavir was signed off in the MAR as administered; however, the medication was unavailable for administration.

Review of the facilities Leave of Absence (LOA) sign out book at the front desk revealed Resident #1 signed himself out of the facility on 07/25/22 and 08/02/22. Resident #1 did not sign out for LOA on 08/24/22 as indicated on the MAR for 08/24/22.

Review of the nurses notes for Resident #1 revealed no documented evidence of why Resident #1 did not receive the Ritonavir on 08/24/22, 08/25/22, and 08/26/22. A note dated 08/27/22 at 12:45 P.M. stated the pharmacy was called regarding the whereabouts of Resident #1's Ritonavir. A pharmacy representative stated she would have to call the facility back about the location of medication. The note further stated Resident #1 was aware the medication was not in the facility, pharmacy was called, and a call back was pending. No other notes regarding the whereabouts of Resident #1's Ritonavir were documented in the medical record.

Interview with Licensed Practical Nurse (LPN) #100 on 08/28/22 at 2:00 P.M. revealed Resident #1 was not in the facility, and she was unaware of the status of the Ritonavir. Observation of the medications in the medication cart with LPN #100 at the time of the interview verified no Ritonavir was available for administration for Resident #1.

Interview with the Director of Nursing on 08/28/22 at 2:25 P.M. revealed she was aware of Resident #1's missing Ritonavir and was unaware of the status of the medication.

Review of the facility policy dated 04/01/07 entitled Pharmacy Services Overview revealed the facility will maintain appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements.

Based on observation and staff interview the facility failed to ensure food was stored in a sanitary manner. This had the potential to affect all 95 residents residing in the facility.

Findings include:

Observations of kitchen and food preparation areas on 08/28/22 between 8:30 A.M. and 9:00 A.M. revealed the following:

The walk-in refrigerator contained a box of oranges with multiple oranges that were green in color. The surveyor pulled out four oranges and notified Cook #998 of the findings. Cook #998 proceeded to throw the four oranges away and went back to her work duties and did not address any of the other many discolored oranges noted in the box. Also noted in the walk-in refrigerator was a bag of mixed green lettuce that was open to the air and noticeably brown and wilted and numerous red onions that had begun to turn brown and discolored.

The walk-in freezer contained a bag of chicken cutlets and cheese ravioli open to the air with significant freezer burn.

Dietary Supervisor #998 verified the above findings at the time of discovery.

Based on observation and staff interview the facility failed to ensure its dumpster area was maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 95.

Findings include:

Observation of the dumpster area on 08/28/22 at 1:38 P.M. with Dietary Manager (DM) #900 revealed the following that was verified at the time of discovery.

The dumpster side doors were open.

Two noticeably used adult briefs were observed on the ground.

Numerous food scraps were observed on the ground.

Numerous and various personal protective equipment items were observed on the ground.