Reflections Retirement Community

Based on resident record review, review of personnel files, interview, and facility policy review, the facility failed to ensure self-medication assessments were completed by a licensed professional working within their scope of practice. This affected two residents (Resident #20 and Resident #23) out of two residents reviewed for October 2024 admissions. The census was 30 residents.

Findings include:

Record review revealed Resident #20 was admitted to the facility on 10/07/24 with diagnoses that included diabetes mellitus, edema, polyneuropathy, and pulmonary edema. A Self-Administration Medication Assessment was completed on 10/10/24 by the Executive Director.

Record review revealed Resident #23 was admitted to the facility on 10/05/24 with diagnoses that included chronic diastolic congestive heart failure, cellulitis, muscle weakness, and lymphedema. The Resident Service Evaluation which included the residents ability to self medicate was completed by the Executive Director. The Executive Director signed and dated the assessment on 10/08/24.

Interview with the Executive Director on 11/06/24 at 10:59 A.M. confirmed that she completed the self administration medication assessment for Resident #20 and Resident #23.

Review of the Executive Director's employee personnel file revealed she was not a physician or other licensed healthcare professional.

Review of facility policy titled Admitting a Resident

Based on resident record review, review of personnel files, interview, and facility policy review, the facility failed to ensure that medication orders were received and documented by a licensed professional working within their scope of practice. This affected two residents (Resident #20 and Resident #23) out of two residents reviewed for October 2024 admissions. The census was 30 residents.

Findings include:

Record review revealed Resident #20 was admitted to the facility on 10/07/24 with diagnoses that included diabetes mellitus, edema, polyneuropathy, and pulmonary edema. Review of Resident #20's medication orders revealed that the Executive Director entered the orders for Resident #20's medications into the electronic medical chart on 10/07/24.

Record review revealed Resident #23 was admitted to the facility on 10/05/24 with diagnoses that included chronic diastolic congestive heart failure, cellulitis, muscle weakness, and lymphedema. Review of Resident #23's medication orders revealed that the Executive Director entered the orders for Resident #23's medications into the electronic medical chart on 10/04/24.

Interview with the Executive Director on 11/06/24 at 10:59 A.M. confirmed that she received and documented the medication orders upon admission for Resident #20 and Resident #23.

Review of the Executive Director's employee personnel file revealed she was not a physician or other licensed healthcare professional.

Review of facility policy titled Admitting a Resident

Based on observation, review of medical records, hospital record review, review of facility policies, and interviews, the facility failed to ensure comprehensive and effective systems were in place to provide adequate, necessary and timely wound care services in accordance with acceptable standards of practice and to meet the care needs of all residents. This resulted in Real and Present Danger and actual harm beginning on 06/04/24 when the facility failed to obtain ordered home health wound care services for Resident #22, a resident with complex skin wounds. Resident #22's wounds continued to decline due to the facility's failure to provide monitoring and assessment of the wounds, failure to provide ordered treatment(s) including lymphedema pumps (an intermittent pneumatic compression device with sequential gradient pressure to help decrease lymphedema) causing increased edema and skin trauma due to anti- edema dressings becoming dislodged resulting in large indentations in the resident's skin. On 09/15/24 and 09/17/24, Licensed Practical Nurse (LPN) #210 assisted Resident #22 with showers due to his dressings being soiled and before re-applying dressings, the wounds were observed to be red, swollen and seeping severely. LPN #210 did not notify any medical provider of the change in condition. On 09/19/24, Resident #22 was found to have fallen on the porch and subsequently assessed to have abnormal vital signs including an elevated temperature of 103.1 degrees Fahrenheit and an elevated blood pressure of 210/92 mm/Hg (hypertensive). The resident was transferred to the hospital (on 09/19/24) and admitted with diagnoses of sepsis (the body's extreme response to an infection, a life-threatening medical emergency) and (wound) myiasis (parasitic infection of fly larva (maggots) in human tissue). The resident was admitted and treated with intravenous antibiotics.

Additionally, concerns that did not rise to Real and Present Danger were identified related to the facility's failure to appropriately complete pressure ulcer dressing changes as ordered by the physician and failure to ensure ongoing evaluation/monitoring of skilled wound care was completed for Resident #7 and Resident #13.

This affected three residents (#7, #13 and #22) of three residents reviewed for hospitalization and/or wound care. The facility census was 31.

On 09/24/24 at 5:20 P.M., the Executive Director (ED) and Regional Clinical Director (RCD) were notified Real and Present Danger began on 06/04/24 when the facility failed to obtain home health services (as recommended/ordered) to provide necessary wound care to Resident #22. On 08/06/24 the (outside) Wound Care Clinic ordered lymphedema pumps which the facility declined to accept upon delivery. From 08/06/24 to 09/15/24 the facility failed to ensure adequate, timely and necessary wound monitoring was completed and wound care dressings were in place to prevent the deterioration of the ulcers and development of four plus edema. On 09/15/24 and 09/17/24, Licensed Practical Nurse (LPN) #210 assisted Resident #22 with showers due to his dressings being soiled and before re-applying dressing, the wounds were observed to be red, swollen and seeping severely. LPN #210 did not notify any medical provider of this change in condition. On 09/19/24, Resident #22 was found to have fallen on the porch and subsequently assessed to have abnormal vital signs including an elevated temperature of 103.1 degrees Fahrenheit and an elevated blood pressure of 210/92 mm/Hg (hypertensive). The resident was transferred to the hospital (on 09/19/24) and admitted with diagnoses of sepsis (the body's extreme response to an infection, a life-threatening medical emergency) and (wound) myiasis (parasitic infection of fly larva (maggots) in human tissue). The resident was admitted and treated with intravenous antibiotics.

The Real and Present Danger was abated on 09/27/24 when the facility implemented the following corrective actions:

On 09/19/24 Resident #22 was transferred to the hospital as of 09/30/24 the resident had not returned to the facility.

On 09/25/24 (no time identified) skin assessments were completed on all 31 current residents. Two residents (#7 and #13) were identified as having skin breakdown and the facility verified both residents had orders for home health.

On 09/25/24 at 2:15 P.M. Certified Nurse Practitioner (CNP) #250 was notified via fax of the State agency concerns related to wound care. CNP #250 contacted the DON at 2:30 P.M. and provided no further directives at this time.

On 09/25/24 at 3:00 P.M. an in-service for nurses and caregivers was presented by the DON and Administrator for one LPN and two resident assistants (RAs).

On 09/25/24 at 4:00 P.M. - a management meeting was held and directed by the Administrator, which included the Business Office Manager, Culinary Director, Maintenance Director, Activities Director, and DON. Inservice topics included:

-Documentation of follow up and follow through with outside agencies to secure care needed for residents by charge nurse.

-Notification to physician of changes of condition by charge nurse.

-Ensuring orders were transcribed to the resident's chart by charge nurse or DON.

-Identifying any resident skin issues while being bathed/showered by RAs. RAs would notify the charge nurse who would notify the resident's physician.

Policies reviewed:

Bath/shower with Shower Sheet

Notification of Changes in Resident Status

Documentation- Licensed Nursing.

On 09/25/24 (no time identified) the DON and Administrator reviewed the facility Discharge policy and understanding of its implementation. The facility implemented a plan moving forward for the DON to make recommendations to the Administrator for any residents requiring discharge and the Administrator would execute the discharge.

On 09/25/24 (no time identified) the facility implemented a plan for Weekly Skin assessments to be completed for all residents by the DON and charge nurse beginning 09/25/24 for one month and then every 60 days thereafter. Any skin issues identified would result in the following procedure:

1)Any issues identified would be reported to the primary care physician (PCP) by charge nurse and documented in resident chart. Charge nurse would follow up on PCP notification daily for new orders and DON would monitor daily as well.

2)Physician orders for home health referrals for wound care would be received by the charge nurse, documented in the resident's chart and charge nurse or DON would contact the Home Health company. Charge nurse would follow through daily to ensure timely start of services. DON would monitor this daily.

3)Charge nurse would document in resident's chart the Skilled Nursing Home Health visits. DON to monitor weekly.

4)Charge nurse or DON would assess wounds weekly and document findings in resident charts. DON to monitor weekly. Any changes/concerns would then be communicated to PCP and Skilled Nursing Home Health by the charge nurse or DON and documented as such in resident chart. DON to monitor weekly.

5)Skilled Nursing Home Health would send notes from visit weekly to charge nurse. DON to monitor weekly.

6)Clinical Care Plan meeting would be held to discuss progress of wounds and clarify orders and tasks for all. In attendance would be the ED (Administrator), DON, Charge Nurse, RA staff, and Skilled Home Health representative. This would begin 10/04/24 and would be held weekly for two months and then monthly thereafter.

On 09/25/24 (no time identified) the facility implemented a plan for ongoing monitoring by DON and ED to ensure documentation was complete, accurate and thorough via record review for all residents. Daily checks would be made on all new orders, including those from outside providers, beginning 09/25/24 and continue for two months.

On 09/25/24 (no time identified) the facility implemented a plan for ongoing monitoring of resident skin condition by daily review of the shower sheets by DON beginning 09/25/24 and continuing for two months. Any issues identified would result in notification to physician and follow up on any orders received by the DON or designee. If the facility identified resident care needs were unable to be met per the regulations, a referral to a skilled nursing facility and/or a 30-day discharge notice would be made by DON and ED.

On 09/26/24 at 6:00 P.M. an in-service was held for two LPNs and three RAs with a plan for additional staff to be in-serviced before their next shift. The following information was presented:

-Documentation of follow up and follow through with outside agencies to secure care needed for resident by charge nurse

-Notification to physician of changes of condition by charge nurse

-Ensuring orders were transcribed to the resident's chart by charge nurse or DON

-Identifying any resident skin issues while being bathed/showered by RAs. RAs would notify the charge nurse who will notify the resident's physician.

Policies Reviewed:

Bath/Shower with Shower Sheet

Notification of Changes in Resident Status

Documentation - Licensed Nursing.

On 09/26/24 (no time identified) policies were reviewed and updated by the facility management company.

Beginning on 09/26/24 (no time identified) the facility implemented a plan for ongoing monitoring of home health and Wound Clinic visits by the DON weekly effective 09/26/24 for two months. Any issues identified would result in notification to physician. If the facility identified a resident's care needs could not be met in the facility, a referral to a skilled nursing facility and/or a 30-day discharge notice would be issued for that resident by the DON and ED.

Beginning on 09/26/24 (no time identified) the facility implemented a plan for on-going monitoring of weekly skilled nursing documentation by the DON weekly effective 09/26/24 for two months. Charge nurses would be held accountable for completion of this task.

On 09/26/24 (no time identified) the facility implemented a plan for ongoing monitoring of skin care services to residents to be completed by the DON weekly effective 09/26/24 for two months to ensure care was being provided per physician order.

Beginning on 09/27/24 (no time identified) the facility evaluated the wound care needs of Resident #7 and Resident #13:

-The DON would clarify wound orders with primary care physician (PCP) on 09/27/24.

-The DON would enter wound orders for charge nurses into Care Merge (facility's electronic medical record system) as Tasks on 09/27/24 to inform charge nurses of wound care orders.

-Charge nurses would provide wound care as ordered as of 09/27/24 and inform the PCP of any concerns and document the changes and notification in the resident's chart.

-The charge nurses and DON would review Home Health notes weekly as part of the monitoring for wound care and ensure all orders were being properly carried out and documented in the resident's chart per physician's orders.

-The DON would notify the ED if the facility identified the care needs of the residents could not be met by the facility and the ED would proceed with referrals to skilled nursing facility and/or a 30-day discharge notice to resident.

On 09/27/24 the facility developed a plan should Resident #22 seek re-admission to the facility following his hospitalization and/or skilled nursing care and require continue wound care at that time. The plan included ensuring wound care orders were in place, entering orders were entered into Care Merge, the charge nurses to provide wound care as ordered and inform PCP of any concerns and document the changes and notification in the resident's chart, the charge nurses and DON to review home health and Wound Clinic notes weekly as part of the monitoring for wound care and ensure all orders were being properly carried out and documented in the resident's chart per physician's orders and the DON to notify the ED if the facility determined the resident's care needs could not be met by the facility and the ED would proceed with referrals to skilled nursing facility and/or a 30-day discharge notice to resident.

Although the Real and Present Danger was abated on 09/27/24, the violation remains as the facility was in the process of monitoring and implementing their corrective action.

Findings Include:

1. Closed record review revealed Resident #22 admitted to the facility on 10/31/13 with diagnoses including hypertension, lymphedema, and chronic kidney disease stage 3.

Review of the resident's medication administration record (MAR) revealed an order dated 02/02/24 for Nystatin cream 10,000 units/gram apply to lower bilateral legs three times weekly. Record review revealed no corresponding nursing note related to the order for Nystatin Cream and there was no documented evidence the treatment was being completed.

Review of hand-written orders revealed an order dated 06/04/24 to obtain home health services to help with activities of daily living (ADLs) and dressings to bilateral lower extremities. This order was based on a recommendation from the outside wound clinic that was managing non-pressure related wounds to the resident's lower extremities at this time. Record review revealed no corresponding nursing note related to the order for home health services or evidence documented of any type of follow up for the ordered home health services.

Review of a service plan first initiated 07/04/24 revealed Resident #22 needed monitoring following treatment/procedure for signs of infection or complication related to bilateral lower extremity (BLE) lymphedema and cellulitis. Interventions included encouraging resident to use moisturizing lotions, report any skin changes to staff, staff to report changes to provider, encourage resident to inspect his skin routinely, and assist with dermatology and podiatry appointments as needed. Goals included skin being intact and healthy, and for resident to be at reduced risk for complications.

Review of the medical record revealed no evidence Resident #22 had a service plan related to non-compliance or refusal of care identified by the facility.

Review of a Wound Care Note dated 08/06/24 by Medical Doctor (MD) #260 revealed Resident #22 was being seen as a follow-up appointment related to diagnoses of non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin, non-pressure chronic ulcer of other part of right lower leg with fat layer exposed, venous insufficiency, and lymphedema. Compression dressings were applied to bilateral lower extremities (BLE). Instructions from the physician (included in the Wound Care Note) included non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin was continuing to improve with some small open areas, non-pressure chronic ulcer of other part of right lower leg with fat layer exposed was still draining a moderate to severe amount and silver alginate would need to be used, for venous insufficiency multilayer Unna boots wrap to continue to BLE as well as Calmoseptine around the wound on the right leg that had silver nitrate due to the silver holding too much moisture on the skin and to use silver alginate and ABD pads to the left leg. Additional instructions included scheduling an appointment with a podiatrist, elevating legs, when possible, follow up with wound clinic weekly. The lymphedema pumps had been approved and when delivered to the facility the order was refused. MD #260 stated he would call and speak with the DON because Resident #22 would benefit from the pumps and wanted to use them.

Review of the medical record revealed no evidence Resident #22 saw the podiatrist and there was no documented evidence staff were elevating the resident's legs.

Review of a Wound Care Note dated 08/27/24 by MD #260 revealed Resident #22 was being seen for a follow up related to diagnoses of non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin, non-pressure chronic ulcer of other part of right lower leg with fat layer exposed, venous insufficiency, and lymphedema. Compression dressings were applied to BLE. Instructions from the physician (included in the Wound Care Note) included non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin was continuing to improve with some small open areas, non-pressure chronic ulcer of other part of right lower leg with fat layer exposed continued to improve and may be ready for tubular compression for the next visit. For venous insufficiency, multilayer Unna boots wrap to continue to BLE as well as Calmoseptine around the wound on the right leg that had silver nitrate due to the silver holding too much moisture on the skin and to use silver alginate and ABD pads to the left leg plus wraps. Treatments were to be completed weekly at the Wound Clinic and as needed by the facility. Additional instructions included scheduling an appointment with a podiatrist, elevating legs, when possible, follow up with wound clinic weekly, and MD #260 would work on getting the lymphedema pumps re-delivered.

An additional Wound Care Note from the wound clinic dated 08/27/24 by MD #260 revealed the wraps to Resident #22's right leg had rolled down and Unna boots were reapplied with ABD padding to the upper shin where the wraps had rolled down and anterior ankle and was secured with a gauze roll. Resident #22's left Unna boot was replied with ABD over the weeping area and at anterior ankle for padding and was secured with a gauze bandage roll. Additionally, MD #260 added Spandagrip (tubular elastic support bandage designed for managing sprains, strains, support following cast removal, general edema, joints & muscles and post graft pressure for burn patients) side J to keep the wraps in place, gauze between toes, and gave an order that if the wraps were to roll, remove the Spandagrip and Coban (self-adherent wrap) layer then reapply Spandagrip and contact the wound clinic in addition to following up in one week for a dressing change.

Review of the medical record revealed no evidence Resident #22 saw the podiatrist and there was no documented evidence staff were elevating the resident's legs or that any as needed (PRN) wound care/dressings were completed by facility staff.

Review of physician orders revealed an order dated 08/29/24 to discontinue silver sulfa cream 1%. However, record review revealed no corresponding nursing note related to this order change. In addition, there was no documented evidence when the facility was completing the silver sulfa cream treatment.

Review of a Wound Care Note dated 09/03/24 by MD #260 revealed Resident #22's ace wrap from the last visit to wound care clinic had rolled down and caused a large indentation in both legs. An order was given to please check the patient's lower legs daily, if the wraps were rolling down, please remove the wraps and cleanse the lower legs with soap and water, pat dry and wrap his legs with dry gauze and compression until his next appointment. An order was given for a follow up in one week.

Record review revealed no documented evidence the facility was checking the resident's legs daily, removing the old wraps, and/or applying new wraps as needed.

There were no additional Wound Care Notes in Resident #22's medical record from the Wound Clinic or documented in the resident's medical record after 09/03/24.

Review of a Provider Note dated 09/10/24 by Certified Nurse Practitioner (CNP) #250 revealed Resident #22 was being seen for worsening complication with his lymphedema which was an unstable, chronic illness to bilateral lower extremities (BLE) and Resident #22 stated he had mild increased pain to BLE. Resident #22's legs were wrapped, and treatment was changed weekly at the wound clinic, but the Unna (multilayer wrap) boots were not staying in place causing further swelling above (the boot). Resident #22 was not making any improvement, was non-compliant and in need of a higher level of care as he continues to decline. An order for a hospice consult was given, and orders from wound care clinic stated to provide supportive care, elevate legs as often as possible, lymphedema wraps per clinic orders and still working on getting lymphedema pumps.

Review of the resident's medical record revealed no additional information related to any type of non-compliance or to identify how the resident was non-compliant.

Review of a fax revealed a referral was sent for home health on 09/11/24. There was no documented follow up for the referral.

Review of a note dated 09/12/24 at 11:56 P.M. by Registered Nurse (RN) #218 revealed a new order for hospice evaluation was faxed to a hospice company. There was no follow up information regarding the outcome of the evaluation.

Review of a shower sheet dated 09/15/24 completed by LPN #210 revealed shower was completed and leg treatment continues. There were no skin impairments marked on the shower sheet. In addition, record review revealed no nursing progress notes from this date (09/15/24) or from 09/17/24 when it was identified that LPN #210 also provided the resident with assistance to shower on this date.

Review of a shower sheet dated 09/18/24 completed by Resident Assistant (RA) #225 revealed Resident #22 received a shower and skin impairments noted included swelling, discoloration, drainage/odor, and dry or scaly and Unna boots were in place. There was no documented evidence RA #225 reported Resident #22's skin impairments to the nurse.

Review of a hospice evaluation note received by the facility on 09/24/24 revealed a consult was completed on 09/19/24 with Resident #22 at which time the resident was assessed to be not appropriate for hospice services.

Review of Resident #22's medical record revealed no evidence facility staff were assessing the resident at least once every seven days to determine he remained appropriate to continue to reside in the residential care facility and did not require a transfer to another health care setting based on his skilled nursing/wound care needs.

Review of a nursing note dated 09/19/24 at 2:03 P.M. and entered by an unnamed Agency Nurse revealed Resident #22 was found on the balcony ground after slipping on the wet ground. Resident #22 stated he did not hurt himself or hit his head. Vitals were checked and Resident #22's blood pressure was elevated at 210/92 mm/Hg (hypertensive), temperature elevated at 103.1 (F), heart rate of 98 (tachycardic), oxygen at 91%, and respirations of 24. Resident #22 was transferred to the emergency room for evaluation.

Review of an admission history and physical note for the hospital dated 09/19/24 revealed Resident #22 arrived at the hospital via ambulance for a fever and fall. Resident #22 had edema to bilateral legs with saturated dressings in place and it was unknown when they had last been changed. Upon arrival to the hospital, Resident #22 was febrile and had an elevated heart rate, meeting the criteria for sepsis. The hospital notes revealed Resident #22's legs had been doing well with compressive dressing with treatment at the wound care clinic on 08/27/24, then at the most recent visit on 09/10/24, the right Unna boot had slipped down over halfway of his leg causing severe lower compression of the lower third of the right leg and foot, and the area above it was draining copious amounts of serous fluid. The left dressing was more intact, but there was a concern with the patient's care at the assisted living facility and identification the resident would require an increased level of care. Resident #22 was placed on continuous cardiac monitoring and blood cultures were obtained. Resident #22 was receiving intravenous antibiotics (Vancomycin and Zosyn). Resident #22 was diagnosed with sepsis and cellulitis.

An infectious disease consult note written by MD #260 dated 09/20/24 revealed Resident #22 had non-pressure chronic ulcers of his bilateral lower legs. A plan for Dakin's soaks was initiated to try to make sure any maggots and eggs are killed off. Due to the resident's legs dripping fluid from all open areas, after Dakin's soaks were completed, dry gauze dressings and ace wraps would be applied and changed daily and as needed. Regarding the resident's lymphedema, Resident #22 would need Unna boots upon discharge, but they were not able to be applied at the time of this visit due to the resident having maggots in his wounds. MD #260's note stated he thought Resident #22 should be discharged to an extended care facility at least for a short time for rehab and wound care because he was not appropriate to be at home or in an assisted living. MD #260 stated he had seen Resident #22 for several months now at the wound clinic and was really always sort of scared for his situation. MD #260's note continued to state Resident #22 was last seen in the wound clinic nine days ago and he did not have cellulitis, but his legs were very swollen because his Unna boot slid down on the right leg, and no one took it off. MD #260 stated he did not feel Resident #22 was appropriate for assisted living but when he spoke with the facility's DON, she stated a lot of our patients are that way. On presentation, Resident #22 had maggots in his wounds which were removed, and his right leg was red and hot. Resident #22's temperature was 102.8 (F) (febrile).

Interview on 09/24/24 at 9:18 A.M. with a resident who wished to remain anonymous revealed she was aware of a resident (Resident #22) having a fall outside, and the aide said they had not changed his bandages once and there were maggots in his wound.

Interview on 09/24/24 at 12:13 P.M. with LPN #210 revealed the resident had an order for wound care twice a week. However, record review revealed no written orders for wound care twice a week. During the interview, LPN #210 revealed she had showered Resident #22 on Sunday, 09/15/24, and Tuesday, 09/17/24 and applied new dressings on those dates. LPN #210 stated when she saw Resident #22's wounds on these days they were not fine. She stated Resident #22 urinates down his legs and it soaks into the dressings. LPN #210 stated from the knees down, Resident #22 had vascular lymphedema, and the right leg was very swollen with blisters, multiple open areas, and seeping. The left leg had mild seeping. LPN #210 stated Resident #22 went to the wound clinic weekly until last week when it changed during an appointment on 09/10/24 to every other week and home health was supposed to come in twice a week for wound care. During the interview, LPN #210 stated she had reported the condition of the resident's legs to the DON, but verified she did not notify a (medical) provider or the wound clinic about the state of Resident #22's legs on 09/15/24 or 09/17/24. The LPN also verified she failed to complete an accurate assessment or documentation of the status of the resident's wounds on 09/15/24 and 09/17/24.

Record review revealed the wound clinic note from the visit on 09/10/24 was not available to the surveyor to review during the onsite investigation.

Interview on 09/24/24 at 12:21 P.M. with CNP #250 revealed she believed in assisted living facilities; the staff were only required to change wound care dressings if they were soiled, and home health was supposed to come in for wound care. CNP #250 stated it was her opinion the facility had gone above and beyond for Resident #22. However, no additional information was provided to explain why this was her belief or how she made this conclusion and there was no evidence Resident #22 had been provided home health services for his wound care needs.

Interview on 09/24/24 at 1:00 P.M. with the Administrator revealed home health was required for wound care services in this facility and any skin documentation could be located on the shower sheets or the nurses' notes. The Administrator confirmed there was an order on 06/04/24 for home health services to assist with wound care, but no follow-up information documented, and Resident #22 did not receive home health services. The Administrator stated due to Resident #22's insurance, a pre-authorization had to be completed, and the facility was struggling to get the authorization to go through. The Administrator confirmed there was no documented evidence of the facility staff trying to obtain a pre-authorization for the 06/04/24 home health order, and for the 09/10/24 order there was no follow-up to the fax sent for pre-authorization.

Interview on 09/24/24 at 4:00 P.M. with the Administrator confirmed there was no documentation of Resident #22's worsening skin issues or treatment to wounds being completed. The Administrator confirmed the nurses should have been documenting worsening skin concerns when they were identified. The Administrator verified the hospital notes, from 09/19/24 reflected Resident #22 had maggots in his wounds and a diagnosis of sepsis and there was no documentation of a physician or nurse practitioner being made aware of Resident #22's wounds having a change in condition. The Administrator verified there was no documentation of Resident #22 being non-compliant with wound care except the CNP #250's note on 09/10/24. The Administrator verified the lymphedema pumps were not in use, but also stated MD #260 must be mistaken because pumps were not delivered to the facility as far as she was aware. The Administrator verified there were no orders listed for Resident #22's as needed wound treatment, home health for wound care, daily checks of wraps to legs to ensure they had not rolled down, or for removal of wraps if they did roll down, reapplication of dry dressing and to call wound care clinic for further instructions.

Interview on 09/25/24 at 11:09 A.M. with MD #260 revealed Resident #22 had wounds to his bilateral lower extremities (BLE) for years. MD #260 reported the first time he saw Resident #22 was in June 2024. Resident #22 had lymphedema in both of his legs and without compression he could not keep his skin intact. MD #260 stated he was under the impression Resident #22 was receiving home health services to come in and do wound care at the facility. MD #260 stated Resident #22 was wearing Unna boots, which were multilayer wraps which could typically be worn for a week, but with as much seepage as the resident had, the boots needed changed more often. MD #260 reported during his last routine visit on 09/10/24, Resident #22's Unna boot had rolled down causing copious amounts of drainage. MD #260 stated he ordered Resident #22 lymphedema pumps at one point and the facility refused to accept them upon delivery because the resident had previously cut up the lymphedema pumps. MD #260 stated the facility did not call him to speak with him about the order for the pumps before declining them. MD #260 stated he spoke with the DON about the need for lymphedema pumps, and she was agreeable to accepting them if they were delivered again. MD #260 stated he told the DON that Resident #22 was not appropriate for an assisted living facility, to which the DON stated to him that most of the residents at the facility weren't. MD #260 stated Resident #22 needed a higher level of care to manage his wounds. MD #260 stated myiasis was caused by dirty conditions and it was not something you catch unless you are not being properly cared for. MD #260 stated the facility had never contacted him regarding updates on Resident #22's wounds and the only time he communicated with the facility was if he initiated the communication. MD #260 stated when Resident #22 would come to the wound clinic for care appointments, his wounds were a mess, and the dressings would be falling off with his legs dripping everywhere. MD #260 stated he was unsure what the facility actually did for Resident #22, and he did not believe anyone (from the facility) was checking on him. MD #260 confirmed he had given orders to re-wrap Resident #22's legs if dressings came undone or rolled down, to wash with soap and water, pat dry and apply dry dressing and call him for further instructions and to monitor Resident #22's wounds daily. MD #260 stated the facility clearly was not following orders because during a routine visit on 09/10/24, Resident #22's dressings were rolled down. MD #260 stated if he were notified of a change in wound status, the wound clinic could get Resident #22 in to see him at any time. MD #260 stated sometimes if appointments weren't available and oral medications would not be sufficient, the physician might recommend a resident going to the emergency room. MD #260 stated it takes more than one day for maggots to infest a wound. MD #260 stated Resident #22's condition would not improve due to chronic ulcers so they should be looking at other treatment options if they were not able to meet his needs at their facility or by utilizing home health services. MD #260 stated he was annoyed by the facility's response to him regarding Resident #22 not being appropriate for their facility because if they were aware of that, they were not doing anything to try and fix the problem. MD #260 stated he felt like the facility dropped the ball with Resident #22 and there was no motivation for them to do better.

Interview on 09/26/24 at 11:47 A.M. with Administrator confirmed residents receiving skilled care should be assessed every seven days to ensure they are appropriate for the facility and should not be transferred to a higher level of care. The Administrator confirmed Resident #22 did not have notes or assessments every seven days to ensure he remained appropriate for continuing care in the residential care facility setting.

A policy related to wound care was requested on 09/17/24; however, the facility stated the did not have one.

Review of a policy titled Bath/Shower (dated 04/2024) revealed documentation should include if skin impairments are noted, and the aide or nurse should document on the 24-hour report form and in the progress notes.

Review of a policy titled Notification of Changes in Resident Status (dated 04/2024) revealed staff should notify providers of significant changes in the resident's physical, mental or emotional status. Significant change is defined as a decline or improvement in a resident's status that will not normally resolve itself without interventions by staff or by implementing standard disease-related clinical interventions, and the decline or improvement impacts more than one area of the resident's health status and requires revision of the service plan. Notifications should be made within 24 hours of the observation.

Review of a policy titled Documentation - Licensed Nursing (dated 03/2024) revealed staff should complete relevant assessment data, document resident changes in status by episodes and exception. All documentation should be objective, timely, accurate and thorough. Documentation should include but not be limited to admission, discharge, medications, assessments, change in clinical condition, incidents, notifications of responsible party and provider, as well as care provided and pertinent resident information.

Review of a policy titled Discharge of a Resident (dated 01/2022) revealed it was the policy of the facility to discharge a resident who does not meet the terms for occupancy as stated in the resident contract. The administrator should provide a 30- day written notice of discharge unless delay might jeopardize health, safety, and well-being of resident or others. A resident might be involuntarily discharged if one or more of the following occur: the facility cannot meet the needs of the resident with available supportive services.

2. Record review revealed Resident #7 was admitted to the facility on 08/26/24 with diagnoses including pleural effusion, chronic kidney disease stage 3, and diastolic congestive heart failure. Review of orders revealed Resident #7 had an order dated 08/27/24 for Calmoseptine to buttocks three times a day to prevent skin breakdown.

Review of the service plan dated 08/27/24 revealed no evidence of wound care or pressure offloading interventions.

Review of a nursing note dated 08/27/24 at 4:30 P.M. by LPN #210 revealed Resident #7 was admitted to the facility with a red pressure area to the center of her buttocks with no open areas noted.

Review of orders revealed Resident #7 had orders dated 08/29/24 for home health for nursing, physical therapy, occupational therapy, and speech therapy to evaluate and treat; and an order dated 09/05/24 for skilled nurse to provide wound care to coccyx, cleanse with wound cleanser and pat dry with gauze, apply Calmoseptine, cover with bordered foam dressing, using clean/antiseptic technique, dressing to be changed at a three to four day frequency.

Review of the resident's medical record and treatment administration records revealed no documentation of wound care being completed by facility staff for Resident #7.

Record review revealed no written evaluation/assessment of the resident at least once every seven days related to the skilled nursing wound care to ensure the resident remained appropriate for placement in the residential care facility and did not require a higher level of care.

Interview on 09/26/24 at 9:30 A.M. with the DON and LPN #210 was completed regarding wound care for Resident #7. The surveyor attempted to clarify the orders for the residents' wound care and to determine if the dressings were due to be changed today, so an observation could be made. The DON stated that home health nurse was there once weekly. The surveyor shared with the DON and LPN #210 that based on the orders, a treatment would have been due, as today was day three, and the order was for every three to four days and as needed. LPN #210 revealed the home health nurse was there twice a week, but only did the dressing change once a week. The second visit was more for education purposes. The surveyor shared with the DON and LPN #210 again that the dressing change would like to be observed as part of the current onsite survey. LPN #210 stated that they just changed it on an as needed basis, and she was not sure if the dressing was off or soiled to be changed prn. Again, the surveyor reviewed with the DON and LPN #210 that the order was to change the dressing every three to four days and prn. The surveyor reiterated, that per the written physician order, if home health was only changing the dressing once a week, the facility's nursing staff would have to change the dressing the next time it was due as it was ordered to be done every three to four days. The surveyor reviewed with the DON and LPN #210 that Resident #7's order was set up the same and was to be changed every three to four days and prn. The DON and LPN #210 stated they were not sure when Resident #7's dressing had last been changed. The DON thought it may have been done Tuesday (09/24/24), when the resident had a shower. The surveyor requested to observe the dressing to see what date was on the old dressing to see if the treatment was due to be done. The DON and LPN #210 (along with the surveyor) went to Resident #7's room and LPN #210 asked the resident if she could check her dressing. The resident reported the dressing was coming off and in need of being changed. Resident #7 consented to allow the surveyor to observe her treatment to be performed.

Observation on 09/26/24 at 9:46 A.M. revealed a treatment was completed for Resident #7's pressure ulcer to her left inner buttock. LPN #210 had the resident stand in front of the commode in the bathroom. The nurse prepared supplies, donned gloves and went into the bathroom to do the dressing change. After having the resident stand using her walker for support, the nurse pulled the resident's pants down and removed the old dressing that was partially intact to her buttock but not fully covering the wound. She discarded the old dressing in the trash can. The old dressing was not noted to have a date on it to show when it was last changed. The nurse proceeded to clean the wound with gauze that had been soaked with tap water from the sink and soap from the soap dispenser. She then used the same gloved hands that she removed the old dressing and cleansed the wound to pat the wound dry with gauze and apply Calmoseptine to the wound. She then applied a border dressing over the open area. The nurse then disposed of her supplies, removed her gloves, and washed her hands before leaving the room. LPN #210 was questioned about the wound and the treatment observation made. She verified she did not remove her gloves and perform any type of hand hygiene between the time she started the treatment and when she finished the treatment. She acknowledged she should have changed gloves and performed hand hygiene after removing the old dressing and cleaning the wound before applying the ointment and placing a new dressing over the open wound. She reported she did not think she had to change her gloves because she did not have anything visible on her gloves. She was then asked to describe what she saw with the wound. She stated the wound presented as a Stage II pressure ulcer and the peri-wound area was slightly red. Wound bed was pink tissue. There was a slight layer of peeling skin around the wound. She stated it did have slough present in the wound in the past, but it was looking better. The wound was free of any odors or drainage. The resident tolerated the treatment well.

Interview on 09/26/24 at 11:47 A.M. with Administrator confirmed residents receiving skilled care should be assessed every seven days to ensure they are appropriate for the facility and should not be transferred to a higher level of care. Administrator confirmed Resident #7 did not have notes or assessments every seven days.

3. Record review revealed Resident #13 was admitted to the facility on 07/15/24 with diagnoses including type II diabetes, hypertension, and hyperlipidemia.

Review of orders revealed Resident #13 had orders dated 07/20/24 for barrier cream with foam pad to buttocks daily and as needed for skin breakdown; order dated 07/23/24 for foam dressing for padding to right inner buttock; order dated 07/29/24 for home health skilled nursing to evaluate and treat for a Stage II pressure ulcer to right upper inner buttock, rinse with saline, pat dry, cover with Dakin prep, cover with foam dressing, monitor daily for new symptoms or healing, change dressing every 7 days or as needed; order dated 07/31/24 to cleanse wound to coccyx with warm soapy water and pat dry, apply Calmoseptine and cover with bordered foam dressing every three to four days and as needed; order dated 08/13/24 for oral liquid nutritional supplement 8 ounces twice daily for increase needs related to pressure injury; and an order dated 09/19/24 for home health to evaluate and treat for sore to bottom.

Review of the resident's medical record and treatment administration records revealed no documentation of wound care being completed by facility staff for Resident #13.

Review of a nursing note dated 07/30/24 at 10:58 P.M. by LPN #213 revealed a new order was received for home health skilled nursing to evaluate and treat Stage II (pressure ulcer) to right upper inner buttocks and rinse with sale, pat dry, cover with skin prep, cover with foam dressing, monitor daily, change dressing every seven days and as needed.

Record review revealed no written evaluation/assessment of the resident at least once every seven days related to the skilled nursing wound care to ensure the resident remained appropriate for placement in the residential care facility and did not require a higher level of care.

Review of a nursing note dated 09/19/24 at 12:27 P.M. by an unnamed Agency Nurse revealed Resident #13 was complaining her bottom hurt, was assessed and a possible Stage II pressure ulcer was identified. No signs or symptoms of infection or sloughing noted. Resident #13 requested to be seen by the CNP and nurse informed CNP of wound and resident request.

Review of a service plan dated 09/26/24 revealed Resident #13 needs monitoring following treatment/procedure for signs/symptoms of infection or complication and to be monitored for skin breakdown and wound orders. Interventions included encouraging Resident #13 to use moisturizing lotions, encourage her to report new skin concerns to staff, encourage LPN to report change in skin condition to provider, inspect skin routinely, and assist with dermatology and podiatry appointments as needed. Goals included Resident #13's skin would remain intact and healthy, and she would be at reduced risk for complications.

During an interview on 09/26/24 at 9:30 A.M. with the DON and LPN #210 the surveyor attempted to clarify the orders for the resident's wound care and to determine if the dressing was due to be changed today, so an observation could be made. The DON stated that home health nurse was there once weekly. The surveyor shared with the DON and LPN #210 that based on the orders, a treatment would have been due, as today was day three, and the order was for every three to four days and as needed. LPN #210 revealed the home health nurse was there twice a week, but only did the dressing change once a week. The second visit was more for education purposes. The surveyor shared with the DON and LPN #210 again that the dressing change would like to be observed as part of the current onsite survey. LPN #210 stated that they just changed it on an as needed basis, and she was not sure if the dressing was off or soiled to be changed prn. Again, surveyor reviewed with the DON and LPN #210 that the order was to change the dressing every three to four days and prn. The surveyor reiterated, that per the written physician order, if home health was only changing the dressing once a week, the facility's nursing staff would have to change the dressing the next time it was due as it was ordered to be done every three to four days. DON verified dressing changes were not being completed for Resident #13 as ordered.

On 09/26/24 at 9:46 A.M., a treatment observation was completed for Resident #13. The treatment was performed by LPN #210. The treatment order was to cleanse the wound with warm soapy water, pat dry and apply Calmoseptine, covering with a foam border dressing every three to four days and prn. The old dressing, which was undated, was removed and discarded in the resident's trash can. The treatment was performed while the resident stood in front of her recliner using her walker for support. The nurse then removed her gloves and washed her hands, applying new gloves before proceeding with the treatment. She cleansed the wound, patted it dry, and applied Calmoseptine as ordered. It was then covered with a border gauze. LPN #210 reported Resident #13's wound presented as a Stage II pressure ulcer as it was open and did not have any slough present. The wound was in the middle above the resident's gluteal cleft. The wound bed was slightly pink, and the peri-wound area was also pink. No odors or drainage was noted. The resident tolerated the treatment without any discomforts voiced.

Interview on 09/26/24 at 11:47 A.M. with Administrator confirmed residents receiving skilled care should be assessed every seven days to ensure they are appropriate for the facility and should not be transferred to a higher level of care. Administrator confirmed Resident #13 did not have notes or assessments every seven days.

This violation represents incidental findings of non-compliance investigated under Complaint Number OH00158035.

Based on resident and family interview, staff interview, and medical record review, the facility failed to ensure personal care services were provided to the residents. This affected two (Resident #5 and #11) of three residents reviewed for bathing. The facility census was 31.

Findings include:

1. Review of Resident #5's medical record revealed an admission date of 04/14/24 with diagnoses including diabetes mellitus, dementia, and stave IV chronic kidney disease. Resident #5's care plan stated she required assistance from staff with bathing and a reminder frequency of one-two times weekly.

Review of the shower log sheets from 08/07/24 to 09/18/24 for Resident #5 revealed shower logs were completed on 08/10/24 (refusal) 08/11/24, 08/14/24, 08/17/24, 08/28/24, 08/31/24, 09/07/24, 09/14/24 (refusal), 09/15/24, and 09/18/24 (Does not state completed just that she does not want her showers on first shift). There were no showers or attempted showers on the following five days: 08/07/24, 08/21/24, 08/24/24, 09/04/24, and 09/11/24.

Interview on 09/18/24 at 9:53 A.M. with Resident #5 revealed she was scheduled to receive showers on Wednesdays and Saturdays. She stated they have not been providing all of her showers due to issues with staffing on the weekends. She stated she feels she has to accommodate the staff and has gone a week without taking a shower multiple times since she arrived at the facility.

During an interview on 09/18/24 at 8:05 A.M. with Licensed Practical Nurse (LPN) #111, she stated the residents that require assistance with showers were scheduled two times a week. She stated the aides fill out a shower sheet once the shower was completed. If the resident declines the shower, she stated they will ask three more times on the same shift and if they still decline the next shift will ask one more time.

Interview on 09/18/24 at 11:39 A.M. with the Executive Director and Director of Nursing (DON) revealed that if the shower log sheet was missing, this means the staff did not ask the resident if they wanted a shower on their designated shower days. She also stated the staffing levels were typically low and about every other week the staff miss showers for the residents. The DON verified Resident #5 did not get her showers as scheduled.

2. Review of Resident #11's medical record revealed an admission date of 05/17/23 with diagnoses including Parkinson's disease, osteoarthritis, and muscle weakness. Resident #11's care plan stated she requires direct required assistance from staff with bathing. Resident #11 gets a bath two times per week.

Review of the shower log sheets from 08/02/24 to 09/13/24 for Resident #11 revealed shower logs were completed on 08/07/24, next completed without a date, 08/16/24, 08/21/24, 08/28/24, 08/30/24, 09/04/24, 09/06/24, and 09/13/24. There were no showers or attempted showers completed on 08/02/24, 08/09/24, 08/14/24, 08/23/24, and 09/11/24.

Interview on 09/18/24 at 10:34 P.M. with Resident #11 and her son revealed she was scheduled to receive showers every Wednesday and Friday. Resident #11's son stated he thinks the staff turnover was rough, and he was not sure if there were any specific reasons for this but feels this was what caused residents to go without their showers. Resident #11 also stated he feels that the showers from Friday to Wednesday were too far apart and he will provide additional showers in between.

During an interview on 09/18/24 at 8:05 A.M. with Licensed Practical Nurse (LPN) #111, she stated the residents that require assistance with showers were scheduled two times a week. She stated the aides fill out a shower sheet once the shower was completed. If the resident declines the shower, she stated they will ask three more times on the same shift and if they still decline the next shift will ask one more time.

Interview on 09/18/24 at 11:39 A.M. with the Executive Director and Director of Nursing (DON) revealed that if the shower log sheet was missing, this means the staff did not ask the resident if they wanted a shower on their designated shower days. She also stated the staffing levels were typically low and about every other week the staff miss showers for the residents. The DON verified Resident #11 did not get her showers as scheduled.

This violation represents non-compliance investigated under Complaint Number OH00157331.

Based on record review and interview the facility failed to investigate an incident of elopement. This affected one resident (Resident #3) of three residents reviewed for wandering. The total facility census was 31.

Findings include:

Review of Resident #3's medical record revealed an admission date of 02/12/24 with diagnoses including late onset Alzheimer's disease, anemia, anxiety, hypertension, hypothyroidism, and other symptoms and signs involving cognitive functions and awareness.

Review of Resident #3's service plan dated 02/13/24 revealed that he required hands on assist with most activities of daily living.

Review of a nurse progress note dated 05/19/24 at 5:40 P.M. revealed Licensed Practical Nurse (LPN) #34 was parking (her car) to go into work and Resident #3 was, in a wheelchair, in the parking lot located at the front of the main entrance to the facility. Resident #3 was stating that he was going home. The resident was redirected to the facility. The note further stated that the Director of Nursing and Executive Director were notified of the elopement.

Review of a nurse progress note dated 05/21/24 at 9:50 A.M. revealed a Patient Care Assistant reported to LPN #21 that Resident #3 had been in the parking lot attempting to enter vehicles. The note further states that the Director of Nursing, Executive Director and the resident's Primary Care Provider were notified of the incident.

Review of the facility incident log revealed documentation of only the 05/21/24 incident..

In interview on 06/10/24 at 1:50 P.M. the Executive Director and Director of Nursing confirmed that only the 05/21/24 incident was on the incident log and that there was not an investigation for the 05/19/24 incident.

Review of facility policy titled Elopement Risk and Missing Resident, dated 11/2023, revealed the facility is to notify the primary care provider with in 24 hours of the elopement and that the resident was to be evaluated for injuries and immediate needs when found. Also, the facility is to review and implement an immediate plan for safety

This violation represents non-compliance investigated under Complaint Number OH00154380.

Based on record review, review of the facility's incident/ accident log, review of the facility's investigation of an elopement, staff interview, and policy review, the facility failed to provide adequate supervision and prevent a resident from exiting the facility without staff knowledge. This affected one resident (Resident #3) of three residents reviewed for wandering. The facility census was 31.

Findings include:

Review of Resident #3's medical record revealed he was admitted on 02/12/24 with diagnoses of late onset Alzheimer's disease, anemia, anxiety, hypertension, hypothyroidism and other symptoms and signs involving cognitive functions and awareness.

Review of Resident #3's service plan dated 02/13/24 revealed the resident required hands on assist for most activities of daily living but to be independent with eating, oral care and had no wandering behaviors at that time.

Review of elopement risk assessment dated 02/13/24 revealed the resident to be low risk for elopement.

Review of Resident #3's progress notes revealed the following:

A nurse progress note dated 04/23/24 at 12:30 P.M. revealed a Patient Care Assistant (PCA) reported the resident had no exit seeking, attempted elopement, or going into other resident rooms.

A nurse progress note dated 05/02/24 at 12:30 A.M. revealed Resident #3 had been up and roaming the hallway.

A nurse progress note dated 05/09/24 at 10:00 A.M. revealed Resident #3 was wandering in and out of other resident rooms and common areas.

A nurse progress note dated 05/14/24 at 11:45 P.M. revealed Resident #3 was wandering the hallway and was found in front of the main entrance doors.

A nurse progress note dated 05/16/24 at 9:30 P.M. revealed Resident #3 was wandering the hallway and attempting to open other residents' doors.

A nurse progress note dated 05/17/24 at 11:50 A.M. revealed Resident #3 was wandering the community in his wheelchair.

A nurse progress note dated 05/19/24 at 5:40 P.M. revealed Licensed Practical Nurse (LPN) #34 was parking to go to work and Resident #3 was in the parking lot, located in front of the main entrance to the facility, sitting in his wheelchair. Resident #3 was stating that he was going home. Resident was redirected to the facility. The note further stated that the Director of Nursing and Executive Director were notified of the elopement.

A nurse progress note dated 05/21/24 at 9:50 A.M. revealed a PCA reported to LPN #21 that Resident #3 had been in the parking lot attempting to enter vehicles. The note further stated that the Director of Nursing, Executive Director and the resident's Primary Care Provider were notified of the incident.

Review of the facility investigation report dated 05/21/24 revealed that an alarm was placed on the resident's door to alert staff when he opened the door and he was to have a one on one sitter provided by the family.

A nurse progress note dated 06/09/24 at 6:00 P.M. Revealed a resident came to LPN #39 and reported that Resident #3 was going out the side door of the common area. The resident was returned by LPN #39.

On 06/10/24 at 1:50 P.M. an interview with the Executive Director and Director of Nursing revealed there was no investigation report for Resident #3's elopement on 05/19/24 at 5:40 P.M.

On 06/11/24 at 9:00 A.M. an interview with the Executive Director revealed the elopement risk assessment dated 02/13/24 is from admission and is the only elopement assessment completed for the resident. The Executive Director also verified the service plan dated 02/13/24 is the current one for the resident and that the service plan is how the PCAs know what care a resident needs.

On 06/11/24 at 9:23 A.M. an interview with LPN #34 revealed on 05/19/24 at 5:40 P.M. LPN #34 was arriving to work and found Resident #3 in the driveway approximately three feet off the sidewalk and directly in front of the building. The resident stated that he was going home and was very difficult to redirect. LPN #34 stated Resident #3 was confused most of the time but had occasional moments of clarity. LPN #34 had not seen exit seeking behavior from this resident prior to this incident, but had seen wandering behaviors.

Review of facility policy titled Elopement Risk and Missing Resident, dated 11/2023, revealed the facility is to notify the primary care provider with in 24 hours of the elopement and that the resident was to be evaluated for injuries and immediate needs when found. Also, the facility is to review and implement an immediate plan for safety.

This violation represents non-compliance investigated under Complaint Number OH00154380.

Based on closed record review and interview the facility failed to comprehensively monitor, provide timely treatment and follow-up for Resident #84 related to a urinary tract infection. This affected one resident (#84) of three sampled residents. The facility census was 31.

Findings Include:

Review of Resident #84's closed medical record revealed the resident was admitted to the facility on 06/01/21 with diagnosis including dementia, diabetes mellitus, hypoglycemia, fatigue, gastroesophageal reflux disease, coronary artery disease, hyperlipidemia, hypertension, thyroid disorder/hypothyroidism. Resident #84 was discharged home on 12/15/23.

Review of Resident #84's nursing progress notes revealed two entries documented in September 2023. The first entry on 09/23/23 at 7:00 P.M. was related to the resident's blood sugar. The next entry dated 09/25/23 at 1:10 P.M. revealed the resident was sitting in the atrium with other residents prior to lunch. She was calling another resident an idiot. The nurse told the resident, We don't call people names and Resident #84 told the nurse to shut-up. Record review revealed no additional nursing progress notes related to the resident's behaviors or interactions with other residents.

The first documented nursing progress note in October 2023 was dated 10/08/23 and revealed the resident received a flu vaccine on this date. The next entry, dated 10/25/23 at 3:25 P.M. revealed a new order for urinalysis and urine culture and sensitivity. Resident aggressive towards other residents. There was no additional assessment or information as to actual symptoms of a urinary tract infection the resident was exhibiting or to detail the circumstances of the resident's aggression.

On 10/26/23 at 7:35 P.M. a nursing progress note revealed lab results faxed to doctor's office. There was no documented evidence the resident's family was notified of the lab results or plan for care for the resident at that time. In addition, review of the nursing progress notes revealed no immediate follow-up to the note on 10/26/23. There was no evidence of the actual lab results, no evidence of physician communication after the results were faxed at 7:35 P.M., no evidence treatment was initiated or warranted, and no physical assessment of the resident related to her urinary status.

A progress note, on 11/06/23 (11 days after the lab results were faxed to the physician) revealed spoke with daughter in law, physician sent prescription to Wal-Mart for urinary tract infection (UTI) last week and prescription was to be delivered by Fed-Ex. As of this morning, prescription remains at pharmacy; Fed-Ex had not picked it up to deliver. The daughter in law indicated it would be delivered today. Called Wal-Mart pharmacy regarding prescription and was told Fed-Ex picked it up and it was enroute to be to the facility today or tomorrow.

A progress note, dated 11/07/23 at 12:30 P.M. revealed new order for (antibiotic) Keflex 500 milligrams (mg) three times per day for ten days. A note at 7:55 P.M. revealed the antibiotic was ordered for a diagnosis of UTI.

Between 11/07/23 and 11/16/23 progress notes reflected the resident was receiving the antibiotic. Some of the notes indicated the resident had no adverse reaction. Four of the notes over the ten-day period included the resident's temperature (the resident was noted to be afebrile). None of the progress notes included any type of bladder/urinary tract assessment or effectiveness of the treatment of the urinary tract infection. The resident received the last dose of antibiotics on 11/16/23 at 10:00 P.M., per the nursing progress note.

Review of the resident's medical record revealed between 11/17/23 and 12/15/23 when the resident was discharged home, there was no evidence of any type of assessment or monitoring of the resident's urinary status or resolution of the urinary tract infection she had recently been treated for. On 12/09/23 at 12:40 P.M. a nursing progress note revealed the resident was threatening another resident.

On 01/19/24 from 12:44 P.M. to 1:22 P.M. telephone interview with Resident #84's family revealed upon admission, June 2021 the resident was higher functioning, was able to complete her own activity of daily living care (with the exception of medication administration) and was pretty alert and oriented even though she had a diagnosis of dementia. The family member denied the resident had any type of behavioral or psychiatric disorders/conditions. The family member indicated the resident's dementia was in the early stages. In September 2022, the family was contacted and informed the resident's level of care was being decreased from a Level 2 to Level 1 because she was doing so well. The family member indicated Level 1 care was basic care and charged at a lower rate than Level 2 care. The family member indicated the resident had been doing well until September-October 2023 when she started getting increased calls from the facility that the resident was having behaviors, she was threatening others, punching people, her mental clarity had gone down and her hygiene practices had deteriorated. The family member indicated in October 2023, the nursing director reached out to her suspecting the changes in the resident's condition might be related to a urinary tract infection and that the facility wanted to do a urine test. The family member revealed she agreed to this but then didn't hear anything else until she got a call from Wal-Mart pharmacy on 11/03/23 that an antibiotic needed to be picked up for the resident. After following up with the facility, she was told the resident had a urinary tract infection and Fed-Ex delivered the medication on Monday 11/06/23. The prescription was for Cephalexin 500 milligrams (mg) twice a day for five days. The resident's family member revealed she was unaware if the medication had actually been administered to the resident and had no knowledge of the facility re-checking the resident's urine to see if the infection had resolved. The family member revealed she was unsure what monitoring was being completed related to the infection. Around mid-November 2023, the family member indicated she was contacted and told the facility was increasing the resident's rate significantly each month due to the resident's increased care needs. The family member stated due to the care concerns she was having and the increase in cost, the family made the decision to discharge the resident from the facility and bring her home with a planned discharge for 12/15/23. Resident #84's family member revealed upon bringing the resident home, she had significant concerns about the resident's well-being and medical status. She made a doctor's appointment, and the resident was seen by the physician on 12/19/23. During the physician visit, concerns were identified including but not limited to the resident having a urinary tract infection. Laboratory testing was completed and on 12/20/23 the resident was started on the antibiotic, Macrobid 100 mg twice a day for seven days for a urinary tract infection. The resident's family member revealed she was later contacted by the physician's office and instructed to take the resident to the emergency room based on the urine test results and what she stated she was told was that the resident had an aggressive bacteria that required intravenous antibiotics to treat. The family member revealed she took the resident to Knox Community Hospital. The resident's family member indicated the urinary tract infection was then properly treated and the resident returned to her baseline without the increased behaviors and overall decline she had previously been experiencing. Resident #84's family member revealed she believed the facility failed to provide the necessary care for the resident related to the urinary tract infection.

On 01/24/24 at 2:55 P.M. interview with Licensed Practical Nurse (LPN) #115 verified there was no documented information about Resident #84's family being notified of the positive urinalysis laboratory results on 10/26/23 or that doctor was notified of the culture and sensitivity results on 10/29/23. He also verified there was no documentation in the progress notes from 10/26/23 until 11/05/23 in regards to the resident's health/urinary status. LPN #115 verified antibiotic treatment did not start until 11/07/23.

This violation reflects non-compliance investigated under Complaint Number OH00149925.

Based on observation, record review, facility policy review and interview, the facility failed to ensure medications were available and administered as ordered for Resident #89. This affected one resident (#89) of two residents observed for medication administration.

Findings Include:

Record review revealed Resident #89 admitted to the facility on 01/10/23 with diagnoses including chronic kidney disease, gastro-esophageal reflux disease, deep vein thrombosis, hyperlipidemia, hypertension, osteoporosis, and left foot drop.

Review of the resident's physician ordered medications revealed an order for Fiber-Lax oral tablet 625 milligrams (mg) one tablet by mouth daily. The resident also had an order for Loratadine 10 mg one tablet by mouth daily.

On 01/18/24 at 9:47 A.M. Licensed Practical Nurse (LPN) #105 was observed administering medications to Resident #89. During the administration, the LPN did not provide the resident her Fiber Lax medication as the medication was noted to be a different dose than what was ordered for the resident. In addition, the LPN did not administer the resident her Loratadine 10 mg due to the medication not matching the physician order.

Interview on 01/18/24 at 10:04 A.M. with LPN #105 confirmed the Fiber Lax and Loratadine medications were not administered as ordered due to the medication being available for the resident not matching the physician ordered medication. The facility had Fibermax 750 mg.

Review of the facility policy for Medication Management, Administration and Storage (Indiana and Ohio Only), dated 03/2022 and last revised 01/2024 revealed the purpose of the policy was to ensure that resident safety was maintained when managing, preparing, administering, and storing all medications while complying with state and federal guidelines. The Community would have available, on the premises or on call, the services of a licensed nurse at all times. The policy included medication administration would be administered as ordered by the resident's provider and would be administered by a licensed nurse or a QMA.

This violation represents non-compliance investigated under Complaint Number OH00149925. This violation is also an example of continued non-compliance from the survey dated 01/09/24.

Based on closed record review and interview the facility failed to complete an accurate and comprehensive reconciliation of Resident #84's medication with the resident's family upon the resident's permanent discharge from the facility. This affected one resident (#84) of three sampled residents. The facility census was 31.

Findings Include:

Review of Resident #84's closed medical record revealed the resident was admitted to the facility on 06/01/21 with diagnosis including dementia, diabetes mellitus, hypoglycemia, fatigue, gastroesophageal reflux disease, coronary artery disease, hyperlipidemia, hypertension, thyroid disorder/hypothyroidism. Resident #84 was discharged home on 12/15/23.

Record review revealed the resident did not self-administer medications; she required medication administration by a nurse one to two times per day.

The most current Service Plan Detail dated 11/29/23 revealed Resident #84 required medication passed by a nurse one to two times a day.

Review of the resident's physician medication orders, dated 12/04/23 revealed the resident had current medication orders (with start dates of 04/30/222) for:

Armour thyroid oral tablet 90 milligrams (mg) one tablet once daily for thyroid disorder.

Metoprolol Succinate (blood pressure medication) extended release 25 mg by mouth once daily.

Omeprazole (medication for heartburn) oral delayed release capsule 40 mg one capsule by mouth daily 30-60 minutes before a meal. Pioglitazone (an antidiabetic medicine) oral tablet 45 mg one tablet once daily.

Simvastatin (lipid lowering medication) 80 mg one tablet at bedtime.

Vitamin D3 1.25 mg (50,000 units) one capsule weekly (on Monday).

On 01/19/24 from 12:44 P.M. until 1:22 P.M. telephone interview with Resident #84's family member revealed concerns related to medication administration for Resident #84. During the interview, Resident #84's family member revealed family managed the resident's medication prescriptions and refilling prescriptions at a local pharmacy but then paid for medication administration services- having facility staff administer the resident her medications. The family member indicated there had been some initial concerns with medication administration following the resident's admission in June 2021 so she began keeping good records and track of when medications were filled and delivered to the facility. The resident's family member revealed when the resident was discharged home and she went to pick her up, on 12/15/23, Licensed Practical Nurse (LPN) #105 gave her the resident's medications. Upon inspection of the medications, she noticed concerns that some of the medication bottles were dated from 10/23/23 and 11/25/23 and felt they contained too many medications in the bottles making her suspect the medications had not actually been administered to the resident as ordered. The family member indicated she questioned LPN #105 about this, and he just chuckled and said he had no explanation. The resident's family member denied LPN #105 reconciled the medications or reviewed what medications or number of tablets were being sent home with the resident at the time of discharge. The resident's family member indicated after arriving home she looked better at the medications and determined the facility sent home with her a bottle of Vitamin D3 50,000 units which was ordered to be given once a week. The prescription had been filled on 10/23/23 and contained 12 capsules in the bottle, leaving the daughter to conclude the medication had not been administered at all since she had dropped it off in October 2023. The daughter had been given a prescription bottle with Metoprolol, which the resident took daily, dated 10/23/23 which had been filled with 30-day supply, but contained 57 tablets. The resident's daughter found similar concerns with the resident's prescription bottles of Simvastatin, Omeprazole, Pioglitazone, and Thyroid (Armour) medications. The facility gave her multiple medications from medication bottles dated for 10/23/23 and 11/25/23 again making her conclude the medications had not been administered to the resident as ordered as these mediations should not have been available in the quantity they were.

Review of the facility Medication Administration Records from 06/01/23 to 12/15/23 for Resident #84 revealed staff documented the administration of the resident's physician ordered medication daily as ordered. There were no resident refusals documented, no times documented when the resident was out of facility and did not receive medications or missing entries on the record to indicate the medication(s) were not administered.

During a follow up interview on 01/24/24 at 10:40 A.M. with Resident #84 family member, the family member again shared she had concerns with the resident's medication administration by facility staff based on the medication bottles and number of medications sent home with her at the time of the resident's discharge. The family member shared she had counted and taken pictures of the resident's medication bottles and actual pills after arriving home with the resident on 12/15/23. The family member revealed as of this date she had received no explanation or additional information to this concern that she had shared with the nurse at the time of discharge and following discharge (date not provided).

Review of photographic evidence on 01/24/23 revealed at the time of the resident's discharge on 12/15/23 the family was provided medications in their original medication bottles. The prescription bottles were dated 10/23/23 and 11/25/23 and were noted to be from Wal-Mart pharmacy. The pictures provided by the family included 51 tablets of Armour Thyroid (90 mg) which amounted to 41 extra tablets. There were 57 tablets of Metoprolol (25 mg) which amounted to 47 extra tablets. There were 51 tablets of Omeprazole (40 mg) which amounted to 41 extra tablets. There were 16 tablets of Pioglitazone (45 mg) which amounted to six extra tablets. There were 25 tablets of Simvastatin (80 mg) which amounted to 15 extra tablets. There were 12 Vitamin D3 capsules in a bottle dated 10/23/23 with directions to administer one capsule weekly.

On 01/24/24 at 12:20 P.M. interview with the Director of Nursing (DON) revealed facility staff do not count medications when a resident is discharged but stated at other facilities she had worked at staff would count the medications upon discharge.

On 01/24/24 at 12:42 P.M. interview with LPN #105 verified he did not count the medications with the family when Resident #84 was discharged, and he stated he was unaware why there would be that much extra medications left. LPN #105 revealed the facility did not have a formal discharge sheet they just sent a copy of resident's code status, physician's orders and a list of any upcoming appointments with residents/family members at the time of a resident's discharge.

On 01/24/24 at 1:15 P.M. interview with the Administrator revealed Resident #84's family had spoken with her about medication concerns by phone after Resident #84 discharge. The Administrator stated the family thought the resident was not getting her medications as ordered and she checked the medication administration record, and noted it was signed by staff that medications were given. The Administrator denied doing any further investigation into the medication concerns.

This violation reflects non-compliance investigated under Complaint Number OH00149925.

Based on closed record review and interview the facility failed to timely identify an ear ache for Resident #84, failed to ensure the resident's transfer to the emergency room was medically justified and failed to ensure notification occurred to the resident's correct responsible party related to the resident's change in condition and need for medical treatment. This affected one resident (#84) of three sampled residents.

Findings Include:

Review of Resident #84's closed medical record revealed the resident was admitted to the facility on 06/01/21 with diagnosis including dementia, diabetes mellitus, hypoglycemia, fatigue, gastroesophageal reflux disease, coronary artery disease, hyperlipidemia, hypertension, thyroid disorder/hypothyroidism. Resident #84 was discharged home on 12/15/23.

Review of the resident's nursing progress notes revealed an entry dated 11/16/23 at 10:00 P.M. which revealed the resident had been administered her last dose of antibiotics for a urinary tract infection.

The next nursing progress note, dated 11/23/23 at 6:30 P.M. revealed the resident complained of left sided head pain radiating to her left jaw and neck and stated it had been occurring for two days. The note documented the resident requested to go to the emergency room. The note indicated the resident's family was called at 7:00 P.M. no answer, left message. Review of the nursing progress notes revealed no assessment or identification of this concerns documented during the two days prior to this note.

The next nursing progress note, dated 11/23/23 at 10:25 P.M. revealed the resident returned from the emergency room via ambulance with a diagnosis of otitis externa left ear with a new order for antibiotic ear drops. Otitis externa involves inflammation (either infectious or non-infectious) of the external auditory canal, sometimes extending to the pinna or tragus. Otitis externa can be acute or chronic.

On 11/24/23 at 11:00 P.M. a nursing progress note revealed the resident took her bedtime (HS) meds earlier, no complaint of ear discomfort. Antibiotic ear drops not in yet.

Review of the nursing progress notes revealed the antibiotic ear drops were started for the resident on 11/26/23 at 12:50 P.M. (three days after the resident had been seen in the emergency room).

On 01/18/24 at 2:29 P.M. interview with the Administrator revealed the facility had miscommunicated when a Resident #84's responsible party was out of town and something happened and the right person didn't get notified. Staff called the next person on the resident's contact list instead of who the first contact wanted them to call in the situation.

On 01/19/24 from 12:44 P.M. until 1:22 P.M. telephone interview with Resident #84's family member revealed she was the resident's emergency contact and the person to be notified in the event of any type of change in condition. The family member revealed the facility contacted her all the time regarding various different things. During the interview, the family member voiced concerns including but not limited to this situation on 11/23/23 when she felt the resident was unnecessarily transferred to the emergency room for an earache and the facility did not properly communicate the resident's condition to an appropriate family member. Resident #84's family member revealed over Thanksgiving she was going to be out of town and had communicated this to two different staff at the facility. The family member revealed, if the facility needed anything with the resident, they were to contact her brother-in-law in her absence. The family member indicated while she was out of town, Resident #84 reported she had an ear ache and that she needed to see a doctor but had no way to get to the doctor's office. The family member revealed instead of calling the doctor to report this concern (and obtain a treatment or make an appointment with the doctor) or calling her brother-in-law, they sent the resident via ambulance to the emergency room where she was diagnosed with an ear infection. The family member revealed this was an unnecessary trip to the emergency room and voiced concerns that neither her brother-in-law or physician were contacted first to address the concern in the facility. The resident's family member revealed as a result of the emergency room visit, on 11/24/23 a prescription for the antibiotic Cipro/dexa drops, four drops twice daily for 19 days were ordered. The prescription was filled at Wal-Mart which she picked up following her return from being out of town.

This violation represents non-compliance investigated under Complaint Number OH00149925.

Based on record review and interview the facility failed to obtain a physician's signature on telephone orders within 14 days as required. The facility also failed to prevent medication orders from being changed without a physician's order. This affected two residents (#10 and #20) of two residents reviewed. The facility census was 29.

Findings include:

1. Review of the medical record for Resident #10 revealed an admission date of 01/16/21. Diagnoses included dementia with anxiety disorder, cerebrovascular accident (CVA) and insomnia.

Review of the physician order and nurse's notes dated 11/18/23 revealed Resident #10 was admitted to Echo Hospice.

Review of physician's telephone orders from Echo Hospice for Resident #10 dated 11/29/23 at 1:45 P.M., 12/08/23 at 1:00 P.M. and 12/10/23 at 1:00 P.M. revealed no physician signatures as of 01/04/24.

Review of nurses notes for Resident #10 dated 11/20/23 at 12:45 P.M. stated Ativan DC'd per Echo Hospice by Licensed Practical Nurse (LPN) #33.

Review of Medication Administration Record (MAR) dated 11/01/23 to 11/30/23 for Resident #10 revealed an undated order for Ativan (anti-anxiety medication) 0.5 milligrams (mg) give one tablet as needed every four hours for anxiety/agitation was discontinued on 11/20/23.

No order could be found from Echo Hospice for the nurses note for Resident #10 made by LPN #33 on 11/20/23.

Review of physician telephone orders from Echo Hospice for Resident #10 dated 11/29/23 at 1:45 P.M. by LPN #33 revealed to discontinue Ativan 0.50 mg twice a day (BID) and as needed (PRN) and Ativan 0.25 mg one tablet orally (po) BID and PRN every four hours had no physician signature.

Review of the Medication Administration Record dated 11/01/23 to 11/30/23 for Resident #10 revealed the discontinuation of an undated order for Ativan 0.5 mg PRN every four hours and Ativan 0.5 mg every four hours as needed on 11/29/23, the start of an undated order for Ativan 0.25 mg one tablet orally as needed every four hours and Ativan 0.25 mg one tablet orally BID had no physician signature.

Interview on 01/04/24 at 2:10 P.M. with the Director of Nursing (DON) revealed telephone orders were taken over the phone or verbally from their facility nursing staff from other providers like hospice or home health agencies and they were filled out by the nurse, faxed to the physician for a signature and then sent to the pharmacy so signatures were obtained fairly quickly.

Interview on 01/08/24 at 8:32 A.M. with the DON and the Administrator verified for Resident #10 the Echo Hospice telephone orders dated 11/29/23 at 1:45 P.M., 12/08/23 at 1:00 P.M. and 12/10/23 at 1:00 P.M. revealed no physician signatures and there was no order for the 11/20/23 discontinuing of the Ativan medication by LPN #33 as of 01/08/24.

Interview on 01/08/24 at 12:00 P.M. with the Administrator and the DON revealed after speaking with the Echo Hospice DON the physician telephone order from Echo Hospice for Resident #10 dated 11/29/23 at 1:45 P.M. by LPN #33 revealed the discontinuation of Ativan 0.50 mg BID and PRN and Ativan 0.25 mg one tablet PO BID and PRN every four hours with no physician signature were never given by their providers and they would fax over the verified 12/08/23 at 1:00 P.M. and 12/10/23 at 1:00 P.M. orders with signatures. He was not aware of an order for 11/20/23 discontinuing the Ativan and there were no notes to support this from the provider.

2. Review of the medical record for Resident #20, revealed an admission date of 08/04/22. Diagnoses included dementia and fatigue.

Review of the physician order and nurse's notes dated 12/20/23 revealed Resident #20 was admitted to Echo Hospice.

Review of physician telephone orders from Echo Hospice for Resident #20 dated 12/22/23 at 1:00 P.M., 12/22/23 at 9:30 P.M. and 12/26/23 at 3:30 P.M. revealed no physician signatures as of 01/08/24.

Interview on 01/04/24 at 2:10 P.M. with the DON revealed telephone orders were taken over the phone or verbally from their facility nursing staff from other providers like hospice or home health agencies and they were filled out by the nurse, faxed to the physician for a signature and then sent to the pharmacy so signatures are obtained fairly quickly.

Interview on 01/08/24 at 10:22 A.M. with the DON verified the physician telephone orders from Echo Hospice for Resident #20 dated 12/22/23 at 1:00 P.M., 12/22/23 at 9:30 P.M. and 12/26/23 at 3:30 P.M. revealed no physician signatures as of 01/08/24.

Interview on 01/08/24 at 1:14 P.M. with the DON revealed after speaking with Echo Hospice DON the physician telephone orders from Echo Hospice for Resident #20 dated 12/22/23 at 1:00 P.M., 12/22/23 at 9:30 P.M. and 12/26/23 at 3:30 P.M. verified the orders were from their prescriber and they would fax over the signed orders.

This violation represents non-compliance investigated under Complaint Number OH00149653.

Based on record review, interview, and policy review, the facility failed to document behaviors exhibited to support/justify the administration of as needed medications, failed to document the outcome of the administration and failed to ensure orders from a physician were followed. This affected one (Resident #20) of two residents reviewed. The facility census was 29.

Findings include:

Review of the medical record for Resident #20 revealed an admission date of 08/04/22. Diagnoses included dementia and fatigue.

Review of the nurses notes for Resident #20 dated 12/15/23 to 12/26/23 revealed no documentation related to the need for as needed medications for agitation due to behaviors except on 12/23/23.

Review of the physician telephone order from Echo Hospice for Resident #20 dated 12/22/23 at 1:00 P. M. revealed Lorazepam 0.5 milligram (mg) tab, 1 tab PO (orally) every 6 hours scheduled for agitation, restlessness and agitation. Lorazepam 0.5 mg tab, 1 tab PO every 1 hour PRN (as needed).

Review of physician telephone orders from Echo Hospice for Resident #20 dated 12/22/23 at 9:30 P.M. revealed discontinue Xanax 0.5 mg PRN and Xanax 0.5 mg scheduled at bedtime (HS), and discontinue Xanax when Ativan (Lorazepam) arrives.

Review of the Control Substance Record Form for Lorazepam 0.5 mg revealed tablets were received on 12/23/23 by Licensed Practical Nurse (LPN) #33 but the medication was not administered until 12/25/23 at 6:35 P.M.

Review of the Control Substance Record Form for Alprazolam (Xanax) 0.5 mg dated 11/30/23 revealed LPN #33 had given doses on the following dates and times: 12/23/23 at 8:00 P.M., 12/24/23 at 1:30 P.M. and 12/24/23 at 8:00 P.M.

Review of the Control Substance Record Form for Resident #20 for Alprazolam 0.5 milligram (mg) tablet dated 11/30/23 revealed doses were signed out for the resident between the dates of 12/15/23 to 12/24/23; Alprazolam 0.5 mg tablet dated 10/10/23 revealed a dose was signed out on 12/26/23 and Lorazepam 0.5 mg tablet dated 12/23/23 had doses signed out for the resident between the dates of 12/25/23 to 12/27/23.

Review of the corresponding Medication Administration Record (MAR) from 12/01/23 to 12/31/23 revealed the doses signed out for the resident on the Controlled Substance Record Forms could not be verified as being administered to the resident due to an inability to understand the record due to incorrect dates or no dates, no times, and missing signatures on administering medications.

Interview on 01/08/23 at 12:10 P.M. with the Director of Nursing (DON) verified Resident #20's nurses notes did not contain any documentation except for on 12/23/23 related to as needed agitation medication given to the resident. The DON revealed the lack of follow up assessment for the effectiveness of the administration of the medication. The DON also verified she was unable to confirm the medications were given on the MAR as noted being signed out on the controlled substance records. The DON stated I didn't even know what to give her when I started here because the MAR was so messed up.

Interview on 01/08/23 at 12:42 P.M. with the DON revealed LPN #33 did not follow the order from Echo Hospice on 12/22/23 of stopping the Xanax when the Lorazepam arrived.

Review of the facility policy titled Medication Management, Administration, & Storage last revised 10/31/23 revealed PRN ( as needed ) medications: may be administered, document in the resident record reported symptoms indicating the need for the medication and the time of the symptoms and the residents reported response to PRN medications will be recorded in the residents medical record within one hour after assisting the resident; document the result of the PRN medication (effective/ineffective) in the electronic medical record.

This violation represents non-compliance investigated under Complaint Number OH00149653.

Based on record review, interview and policy review the facility failed to maintain an effective and accurate system for the accounting and administration of controlled substances. This affected two residents (#10 and #20) of two residents reviewed. The facility census was 29.

Findings include:

1. Review of the medical record for Resident #10 revealed an admission date of 01/16/21. Diagnoses included dementia with anxiety disorder, cerebrovascular accident (CVA) and insomnia.

Review of the Medication Administration Record (MAR) dated 11/01/23 to 11/30/23 and 12/01/23 to 12/31/23 for Resident #10 revealed no dates for any orders added as well as documentation of medications on the incorrect dates or no dates, no times, and missing signatures of administering medications.

Review of the Control Substance Record Form for Resident #10 for Ativan (anti-anxiety) 0.5 milligrams (mg) start date 11/27/23 revealed the medication was signed out on the form for Resident #10, but it could not be verified the medication was actually given, due to inadequate documentation on the MAR.

Interview on 01/08/24 at 8:43 A.M. with the Director of Nursing (DON) verified the MAR for Resident #10 dated 11/01/23 to 11/30/23 and 12/01/23 to 12/31/23 had no dates for any orders added as well as documentation of medications on the incorrect dates or no dates, no times, and missing signatures of administering medications.

Interview on 01/08/24 at 8:48 A.M. with the DON verified the MAR for Resident #10 dated 11/01/23 to 11/30/23 and 12/01/23 to 12/31/23 and the Controlled Substance Record Form for Ativan 0.5 mg with a start date 11/27/23 could not be compared for the accurate administration of the medication due to the MAR not containing dates and facility staff documenting on various days and times and for the administration, therefore they were not matching up.

2. Review of the medical record for Resident #20 revealed an admission date of 08/04/22. Diagnoses included dementia and fatigue.

Review of the Medication Administration Record dated 12/01/23 to 12/31/23 for Resident #20 revealed no dates for any orders added as well as documentation of medications on the incorrect dates or no dates, no times, and missing signatures of administering medications.

Review of the Control Substance Record Forms for Resident #20 for Alprazolam 0.5 mg tablet dated 10/10/23, Alprazolam 0.5 mg tablet dated 11/30/23 and Lorazepam 0.5 mg tablet dated 12/23/23 contained entries in which the medications were signed out for the resident. However, based on review of the MAR, there was no evidence the medication had been administered to the resident as needed/ordered. The medication could not be reconciled.

Interview on 01/08/24 at 10:52 A.M. with the DON verified the Medication Administration Record for Resident #20 dated 12/01/23 to 12/31/23 had no dates for any orders added as well as documentation of medications on the incorrect dates or no dates, no times, and missing signatures of administering medications.

Interview on 01/08/24 at 11:01 A.M. with the DON verified the MAR for Resident #20 dated 12/01/23 to 12/31/23 and the Control Substance Record Forms for Resident #20 for Alprazolam 0.5 mg tablet dated 10/10/23, Alprazolam 0.5 mg tablet dated 11/30/23 and Lorazepam 0.5 mg tablet dated 12/23/23 could not be compared for accuracy due to the MAR not containing dates and facility staff documenting on various days and times and for the administration, therefore they were not matching up.

This violation represents non-compliance investigated under Complaint Number OH00149653.

Based on record review, interview and policy review, the facility failed to maintain a complete and accurate medication administration record. This affected two residents (#10 and #20) of two residents reviewed. The facility census was 29.

Findings include:

1. Review of the medical record for Resident #10 revealed an admission date of 01/16/21. Diagnoses included dementia with anxiety disorder, cerebrovascular disorder (CVA) and insomnia.

Review of the Medication Administration Record (MAR) dated 11/01/23 to 11/30/23 and 12/01/23 to 12/31/23 for Resident #10 revealed no dates for any orders added as well as documentation of medications on the incorrect dates or no dates, no times, and missing signatures of administering medications.

Interview on 01/08/24 at 8:43 A.M. with the Director of Nursing (DON) verified the MAR for Resident #10 dated 11/01/23 to 11/30/23 and 12/01/23 to 12/31/23 had no dates for any orders added as well as documentation of medications on the incorrect dates or no dates, no times, and missing signatures of administering medications.

2. Review of the medical record for Resident #20 revealed an admission date of 08/04/22. Diagnoses included dementia and fatigue.

Review of the MAR dated 12/01/23 to 12/31/23 for Resident #20 revealed no dates for any orders added as well as documentation of medications on the incorrect dates or no dates, no times, and missing signatures of administering medications.

Interview on 01/08/24 at 10:52 A.M. with the DON verified the MAR for Resident #20 dated 12/01/23 to 12/31/23 had no dates for any orders added as well as documentation of medications on the incorrect dates or no dates, no times, and missing signatures of administering medications.

Review of the facility policy titled Medication Management, Administration & Storage last revised 10/31/23 revealed at the time of administration, the licensed nurse or qualified medication aide administering the medication would document the administration in the medication administration record that includes the following: Resident name, name of medication or treatment, date, time, route, dosage, name or initials of the person administering the drug or treatment and response to the medication for appropriateness of as needed medications (PRNs) and if indicated.

This violation represents non-compliance investigated under Complaint Number OH00149653.

2. Observation of the facility kitchen on 12/12/23 from 8:30 A.M. to 8:50 A.M., revealed there were three opened bags of frozen food in the walk-in freezer with no label or date. The bags were twisted closed. Interview with Dietary Manager #115 at the time of the observation revealed she identified the unlabeled bags as frozen meatballs. Dietary Manager #115 confirmed there were no labels or dates on the bags of meatballs and further confirmed the opened bags should have had been dated when they were opened.

Review of the facility's policy titled Ready-to-Eat Hazardous Food, Date Marking revealed ready-to-eat potentially hazardous foods prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in the kitchen and, if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises or discarded.

This violation is an example of continued non-compliance from the surveys dated 08/05/23, 12/01/22, 09/09/20, and 12/28/18.

Based on review of facility fire drills, staff interview, and facility policy review, the facility failed to ensure fire drills were performed on each shift at least every three months and residents who were capable of self-evacuation were evacuated to safe areas or to the exterior of the building in at least two fire drills a year on each shift. This had the potential to affect all 30 residents residing in the facility. The census was 30.

Findings include:

1. Review of facility fire drills dated August 2023 through November 2023 revealed a fire drill was conducted on second shift in August 2023, a fire drill was conducted on third shift in September 2023, a fire drill was conducted on first shift in October 2023, and no fire drill was conducted in November 2023. Review of the fire drills revealed no fire drill was conducted on second shift during the months of September 2023, October 2023, and November 2023.

Interview with Executive Director #112 on 12/12/23 at 10:50 A.M. confirmed there was no fire drill performed on second shift in November 2023.

2. Review of the facility fire drills, dated January 2023 to November 2023, revealed no evidence to support residents who were capable of self-evacuating to outside the facility or to a safe area, was completed on two shifts during at least two drills a year on each shift.

Interview with Executive Director #112 on 12/12/23 at 10:50 A.M. confirmed they have no evidence to support residents who were independent with ambulation and independent with transferring to a mobility device, were evacuated or moved to a safe area at least twice a year on each shift in the last 12 months.

Review of the facility Fire Safety Training and Drills policy, undated, revealed the facility will conduct appropriate and timely training and fire drills on safety procedures in accordance with state regulations, local fire codes, and Fire Marshal requirements. The executive director (or designee) will conduct periodic fire drills, in compliance with state regulations and local fire codes, rotating the timing of the drills so that all staff has the opportunity to participate.

Based on review of facility disaster drills and staff interview, the facility failed to ensure a tornado drill was completed during the months of March through July. This had the potential to affect all 30 residents residing in the facility. The census was 30.

Findings include:

Review of the facility disaster drills, dated February 2023 and May 2023, revealed two elopement drills were conducted. Review of all fire and disaster drills, dated January 2023 to October 2023, revealed the facility had not perform a tornado drill during the months of March through July.

Interview with Executive Director #112 on 12/12/23 at 10:50 A.M. confirmed the facility did not perform a tornado drill during the months of March through July.

Based on observation, staff interview, and facility policy review, the facility failed to ensure all food was stored and labeled to protect against contamination and spoilage. This had the potential to affect 32 of 32 residents in the facility.

Findings Include:

Observations on 08/05/23 from 10:36 A.M. to 10:55 A.M. revealed the following items were opened in the dry storage with no date as to when they were opened or to be used by: plastic bag of elbow macaroni, and a bag of mini semi sweet chocolate chips.

The following items were opened in the reach in refrigerator with no date as to when they were to be used by:

cherry cheesecake bar times five, three bowls of potato salad, one bowl of tossed salad, and one bowl of cole slaw. There were three pieces of white cake in the refrigerator uncovered.

There were three rusty shelves in the reach in refrigerator.

The following items were opened in the walk in refrigerator with no date as to when they were to be used by: a bag of medium cheddar cheese cubes, and a container of cream of celery soup.

The following items were opened to air in the walk in freezer: a bag of cod fillets and two bags of frozen fish triangles.

There were nine boxes stored on the floor in the walk in freezer on Saturday when the delivery day was Wednesday.

Two large Rubbermaid garbage can on wheels (one by the prep table and one by the dishwasher) did not have lids.

Also, three ice buckets were stored wet; stacked on the drying rack.

The sugar was stored with a scoop, clear plastic cup, in the bin.

Interview on 08/05/23 at 10:55 A.M. with Cook #81 verified the kitchen did not own lids for the large garbage cans. Further verified left overs were stored without a date, cake was stored uncovered, boxes were stored on the floor of the freezer, and a scoop was stored in the sugar bin.

Review of the facility undated policy Kitchen Sanitation included all equipment, surfaces, and kitchenware will be allowed to air dry after being sanitized. Plastic liners will be kept tightly covered with lids, emptied, and kept clean inside an out.

Review of the facility undated policy Food-Non Storage included food is stored off the floor in a manner that permits cleaning underneath the shelves, racks, or platforms. Scoops are not to be stored in the food containers, but are to be kept covered in plastic in a protected area near the containers. Freezer storage foods must be wrapped well to prevent freezer burn.

Review of facility Culinary Experience: Inventory, Purchasing, and Storage policy, undated, revealed all food products must be stored in their original container, except when opened or processed; then they may be stored in a covered container. Contents of opened cans must be transferred to a clean container, covered, dated, labeled and refrigerated. All products should be clearly dated as they are removed from the original container to maintain first in, first out rotation. All opened food should be kept in containers that prevent contamination. Such containers should be clearly labeled with the common name of the food. Bulk ingredients must be labeled to prevent confusion.

This violation represents non-compliance investigated under Complaint Number OH00144824.

This violation is evidence of continued noncompliance from the survey dated 12/01/22.

Based on observation and staff interview, the facility failed to store all medications in a safe manner. This had the potential to affect 29 of 29 residents in the facility.

Findings Include:

Observation on 11/29/22 from 8:05 A.M. to 8:09 A.M. revealed two medication carts in the common area of the facility. Both carts were next to each other and were unlocked. Each cart had routine/scheduled and as needed medications for multiple residents within them that were not secured or stored properly.

On 11/29/22 at 8:10 A.M., interview with Licensed Practical Nurse (LPN) #404 confirmed the medication carts were left unlocked and unattended. She stated, Oh, I forgot to lock the carts, didn't I?

Based on personnel record review, staff interview, and facility policy review, the facility failed to perform a tuberculin screening for all employees prior to the first day of employment. This had the potential to affect 29 of 29 residents in the facility.

Findings Include:

Review of the following employee personnel records and tuberculin screening documents revealed they were not screened for tuberculin prior to or on their first day of employment:

Dietary Staff #409 was hired on 11/08/22, but her first step tuberculin screening was not performed until 11/11/22;

Nursing Staff #500 was hired on 11/11/22, but his first step tuberculin screening was not performed until 11/15/22;

Housekeeping Staff #501 was hired on 07/05/22, but her first step tuberculin screening was not performed until 07/06/22.

Interview with Business Office Manager #129 on 11/29/22 at 1:09 P.M. confirmed the hire dates and the dates of the first tuberculin screening of the staff listed above.

Review of facility Medical Examination and Tuberculosis Screening policy, dated 05/26/21, revealed all staff shall be screened for tuberculosis infection and disease using a two step tuberculin skin test (TST) or blood assay mycobacterium tuberculosis (BAMT) and symptom screening, prior to beginning employment.

Based on observation, staff interview, and facility policy review, the facility failed to ensure all food was stored and labeled according to professional standards. This had the potential to affect 29 of 29 residents in the facility.

Findings Include:

Observations on 11/28/22 from 1:35 P.M. to 1:50 P.M. revealed the following items were opened with no date as to when they were opened or to be used by:

plastic bag of frozen vegetables, plastic bag of frozen biscuits, plastic bag of frozen potato wedges, plastic bag of frozen cookies, and plastic bag of frozen apple danishes.

Also, the following were observed as being opened, a handwritten date on the lid of the container, but no indication as to what the date on the container was indicating:

plastic jug of pickles (hand written date of 11/09), plastic jug of thousand island dressing (hand written date of 07/22), french dressing (hand written date 05/18), and balsamic vinaigrette dressing (hand written date 06/10).

Interview with Culinary Supervisor #164 on 11/28/22 at 1:50 P.M. confirmed the items listed above, that were opened and did not have a date on them, should have had a date as to when they were opened and/or when they should be used by. Also, she confirmed she did not know what the hand written dates on the plastic jugs were; whether they were the delivery date to the facility or when they were originally opened. She also confirmed there should be dates on the food items that are opened, in which it is clear what they mean.

Review of facility Culinary Experience: Inventory, Purchasing, and Storage policy, undated, revealed all food products must be stored in their original container, except when opened or processed; then they may be stored in a covered container. Contents of opened cans must be transferred to a clean container, covered, dated, labeled and refrigerated. All products should be clearly dated as they are removed from the original container to maintain first in, first out rotation. All opened food should be kept in containers that prevent contamination. Such containers should be clearly labeled with the common name of the food. Bulk ingredients must be labeled to prevent confusion.